bluuebunny/crossref_metadata_2025_split huggingface dataset:
Death in the Intensive Care Nursery: Physician Practice of Withdrawing and Withholding Life Support
Authors: Wall Stephen N. , Partridge John Colin 
Published: August 2004

Objective. To determine the frequency of selective nontreatment of extremely premature, critically ill, or malformed infants among all infant deaths in a level III intensive care nursery (ICN) and to determine the reasons documented by neonatologists for their decisions to withdraw or withhold life support.
Methods. This was a descriptive study based on review of the medical records of all 165 infants who died at a university-based level III ICN during 3 years. We determined whether each death had occurred despite the use of all available technologies to keep the infant alive or whether these were withheld or withdrawn, thereby leading to the infant's death. We also determined whether neonatologists documented either “futility” or “quality of life” as a reason to limit medical interventions.
Results. One hundred sixty-five infants died among the 1609 infants admitted during the study period. One hundred eight infant deaths followed the withdrawal of life support, 13 deaths followed the withholding of treatment, and 44 deaths occurred while infants continued to receive maximal life-sustaining treatment. For 90 (74%) of the 121 deaths attributable to withholding of withdrawal of treatment, physicians cited that death was imminent and treatment was futile. Quality-of-life concerns were cited by the neonatologists as reasons to limit treatment in 62 (51%). Quality of life was the only reason cited for limiting treatment for 28 (23%) of the 121 deaths attributable to withholding or withdrawal of treatment.
Conclusions. The majority of deaths in the ICN occurred as a result of selective nontreatment by neonatologists, with few infants receiving maximal support until the actual time of death. Neonatologists often documented that quality-of-life concerns were considered in decisions to limit treatment; however, the majority of these decisions were based on their belief that treatment was futile. Prospective studies are needed to elucidate the determinants of neonatologists' practice decisions of selective nontreatment for marginally viable or damaged infants.
Self-sufficiency at Ages 27 to 33 Years: Factors Present Between Birth and 18 Years That Predict Educational Attainment Among Children Born to Inner-city Families
Authors: Hardy Janet B. , Shapiro Sam , Mellits E. David , Skinner Elizabeth A. , Astone Nan Marie , Ensminger Margaret , LaVeist Thomas , Baumgardner Rosemary A. , Starfield Barbara H. 
Published: August 2004

Objectives. Some inner-city infants grow to be successful, self-sufficient adults. This study is designed to identify characteristics from early childhood that foster or impede favorable outcomes and are useful for formulation of public policy.
Methods. Population: 2694 children (G-2s), born 1960 through 1965, to 2307 inner-city women (G-1s) enrolled in the Johns Hopkins Collaborative Perinatal Study. Data: 1) prospective observations (birth through 8 years) of neurologic and cognitive development, health, behavior, and family and neighborhood socioeconomic characteristics and 2) completed interviews with 1758 G-2s (age 27 to 33) and 1552 G-1s, bridging the period from age 9 to present status. An intergenerational, life course model of development identified significant characteristics and events associated with G-2 outcome (education, physical and mental health, healthy lifestyle, and financial independence of public support, emphasizing educational attainment of a high school diploma or a graduate equivalency degree). Multiple logistic regression equations identified independent, predictive variables during infancy, preschool and early school years, and adolescence. The probability of a good outcome was estimated in the presence of combinations of the six variables most strongly associated with that outcome.
Results. Among G-2s, 79% had a successful outcome for education, 60% health, 70% lifestyle, and 76% for financial independence. Black G-2s had more favorable outcomes than white G-2s in education and lifestyle, whites for financial outcome; health did not differ by race. The six variables most predictive of adult education were: G-1 education at G-2 birth and G-2 attainment of honor roll, average or better reading skills at 8 years, avoidance of regular smoking, and pregnancy before age 18, and not repeating a grade in school.
Conclusions. Substantial proportions of inner-city children become successful adults. Attention to improving public education, particularly language and reading skills, and the prevention of smoking and adolescent pregnancy are clearly indicated.
Sleeping Position, Infant Apnea, and Cyanosis: A Population-based Study
Authors: Ponsonby Anne-Louise , Dwyer Terence , Couper David 
Published: August 2004

Objectives. To examine the relationship between usual infant sleeping position and the parental report of infant cyanosis, pallor, breath-holding, and breathing difficulties; and to document hospital admission rates for apnea/cyanosis over time and to describe how admission rates vary by usual sleeping position.
Methods. A prospective cohort study was conducted. It involved the one fifth of Tasmanian live births that were assessed, using a perinatal score, as being at higher risk for sudden infant death syndrome (SIDS). From May 1, 1988 to April 30, 1993, 6213 infants participated in the hospital (4 days postnatal age) and home interview (5 weeks postnatal age) (89% of eligible infants). Data on usual sleep position and infant history of cyanosis were collected at home interview. Hospital admission records for apnea/cyanosis in the first year of life were linked to data on cohort infants in southern Tasmania.
Results. Infants who slept supine were not more likely to have been reported to experience cyanosis, pallor, or breathing problems at 1 month of age, when compared with infants sleeping in other positions. In fact, the risk of cyanosis was higher in the prone, face-down sleeping position than in the supine sleeping position (adjusted odds ratio = 4.21, 95% confidence interval [1.33, 13.28]). Among cohort infants in southern Tasmania, hospital admission rates for apnea/cyanosis did not differ by usual sleeping position or year of birth.
Conclusions. Infants usually sleeping supine do not have increased rates of morbidity in relation to parental reports or hospital admissions for apnea/cyanosis. In a location where SIDS and total postneonatal mortality has fallen after intervention to reduce the prevalence of the prone position, rates of hospital admission for apnea/cyanosis have not changed. infant sleeping position, sudden infant death syndrome, infant cyanosis, infant apnea.
Increasing Immunization: A Medicaid Managed Care Model
Authors: Browngoehl Kevin , Kennedy Kathleen , Krotki Karol , Mainzer Hugh 
Published: August 2004

Objective. To evaluate the impact of an immunization outreach program on immunization rates.
Setting. A Pennsylvania independent practice association model managed care organization (100% Medicaid).
Design. Retrospective cohort study (N = 2511) of children 30 to 35 months of age from two age cohorts that compared immunization rates for Advisory Committee on Immunization Practices schedules for diphtheria-tetanus-pertussis, oral polio vaccine, measles-mumps-rubella, and Haemophilus influenza type b. An evaluation of the outreach component of the program compared treatment and nontreatment subgroups of one age cohort (N = 1002).
Intervention. The immunization program targeted approximately 19 000 members from birth to 6 years of age. The program components included computerized tracking and reminders, member and provider education, provider incentives, member incentives, and home visiting outreach.
Results. Data indicate that the treatment group has higher completed immunization rates at 35 months of age than does the control group. Furthermore, data show that members with home visits have significantly higher completed immunization rates than do other members. The corresponding comparisons for age-appropriate immunizations by 24 months indicate a nonsignificant trend of increased rates.
Conclusion. The data provide evidence supporting a correlation between comprehensive strategies (computerized tracking, member and provider education and incentives, and home visiting) and increased immunization rates. Those individuals who received home visits were more likely to complete an immunization series by 35 months of age than those who did not. However, within the Mercy Health Plan program, age-appropriate immunizations are not significantly affected by home-visiting outreach. immunization, managed care, Medicaid, medical assistance, incentives, home visiting, barriers.
Hospital and Patient Characteristics Associated With Variation in 28-Day Mortality Rates for Very Low Birth Weight Infants
Authors: Horbar Jeffrey D. , Badger Gary J. , Lewit Eugene M. , Rogowski Jeannette , Shiono Patricia H. ,   for the Vermont Oxford Network
Published: August 2004

Background. The outcomes for very low birth weight infants vary among neonatal intensive care units (NICUs), but the reasons for this variation are not well understood. We used the database of a large neonatology research network to determine whether either admission characteristics of the infants or specific characteristics of the units such as annual patient volume and the presence of a pediatric residency program could account for observed differences in neonatal mortality rates among units.Methods. We studied 7672 infants with birth weights from 501 to 1500 g treated during 1991 and 1992 at 62 NICUs participating in the Vermont Oxford Network Database.Results. Overall, 14.7% of the study infants died within 28 days of birth (interquartile range 9.9% to 18.1%). The ratio of the number of observed deaths at an NICU to the number of deaths predicted based on the characteristics of infants treated at the NICU (standardized neonatal mortality ratio, [SNMR]) varied significantly among units (range 0 to 1.69, z = 4.24). There was no association between annual patient volume and either mortality rate (r = .17) or SNMR (r = .22). Observed mortality rates (17% vs 13%) and SNMR (1.04 vs .87) were both higher at the 24 hospitals with pediatric residency training programs than at the 38 hospitals without such programs. Hospitals with residency programs had higher average annual patient volumes (104 vs 66). In an analysis simultaneously adjusting for patient characteristics, volume, and presence of a residency program, neither volume (odds ratio [OR] per 10 additional cases treated 1.01, 95% confidence interval [CI], .98 to 1.04) nor presence of a pediatric residency program (OR 1.18, 95% CI, .94 to 1.47) was significantly associated with neonatal mortality risk.Conclusion. There are differences in neonatal mortality rates among NICUs that cannot be explained by differences in the measured admission characteristics of the infants, suggesting that the effectiveness of medical care varies among units. Neither the annual volume of very low birth weight infants treated in a unit nor the presence of a pediatric residency training program was independently associated with neonatal mortality rates for very low birth weight infants.
Improving Care for Minority Children With Asthma: Professional Education in Public Health Clinics
Authors: Evans David , Mellins Robert , Lobach Katherine , Ramos-Bonoan Carmen , Pinkett-Heller Marcia , Wiesemann Sandra , Klein Ilene , Donahue Caroline , Burke Deirdre , Levison Moshe , Levin Bruce , Zimmerman Barry , Clark Noreen 
Published: August 2004

Objective. Recent studies have shown that lack of continuing primary care for asthma is associated with increased levels of morbidity in low-income minority children. Although effective preventive therapy is available, many African-American and Latino children receive episodic treatment for asthma that does not follow current guidelines for care. To see if access, continuity, and quality of care could be improved in pediatric clinics serving low-income children in New York City, we trained staff in New York City Bureau of Child Health clinics to provide continuing, preventive care for asthma.Methods. We evaluated the impact of the intervention over a 2-year period in a controlled study of 22 clinics. Training for intervention clinic staff was based on National Asthma Education and Prevention Program guidelines for the diagnosis and management of asthma, and included screening to identify new cases and health education to improve family management. The intervention included strong administrative support by the Bureau of Child Health to promote staff behavior change. We hypothesized that after the intervention, clinics that received the intervention would, compared with control clinics, have increased numbers of children with asthma receiving continuing care in the clinics and increased staff use of new pharmacologic and educational treatment methods.Results. In both the first and second follow-up years, the intervention clinics had greater positive changes than control clinics on measures of access, continuity, and quality of care. For second year follow-up data these include: for access, greater rate of new asthma patients (40/1000 vs 16/1000; P &lt; .01); for continuity, greater percentage of asthma patients returning for treatment 2 years in a row (42% vs 12%; P &lt; .001) and greater annual frequency of scheduled visits for asthma per patient (1.85 vs .88; P &lt; .001); and for quality, greater percentage of patients receiving inhaled β agonists (52% vs 15%;P &lt; .001) and inhaled antiinflammatory drugs (25% vs 2%; P &lt; .001), and greater percentages of parents who reported receiving patient education on 12 topics from Bureau of Child Health physicians (71% vs 58%; P &lt; .01) and nurses (61% vs 44%; P &lt; .05).Conclusion. We conclude that the intervention substantially increased the Bureau of Child Health staff's ability to identify children with asthma, involve them in continuing care, and provide them with state-of-the-art care for asthma.
Diagnosis and Management of Posterior Plagiocephaly
Authors: Pollack Ian F. , Losken H. Wolfgang , Fasick Patricia 
Published: August 2004

Objective. The management of infants with posterior plagiocephaly has been controversial both because of widely differing estimates in the literature of the relative frequencies of true lambdoidal synostosis vs positional molding and because of divergent approaches to treating this problem in different institutions. Based on our experience, we hypothesized that the vast majority of children with posterior plagiocephaly did not have true synostosis and that the cosmetic impairment in such patients could be effectively treated with nonsurgical modalities.
Methods. Between 1992 and 1995, we prospectively applied in 71 infants a consistent management philosophy for these malformations that has incorporated a detailed evaluation of sutural anatomy as the basis for a physiologic approach to treatment. This approach has been directed at distinguishing true synostosis from deformational plagiocephaly and at avoiding surgery for patients with deformational abnormalities by using a combination of nonsurgical modalities to restore normal cranial growth dynamics. All children first underwent skull radiographs to determine whether the lambdoidal sutures were patent. In equivocal cases, computed tomography was also performed. Patients without true synostosis were enrolled on a course of positional therapy. In patients that did not improve after 2 to 3 months, a custom-fitted orthoplastic molding helmet was applied to facilitate passive skull recontouring.
Results. Forty children had patent sutures based on skull radiographs, and 29 others, in whom the radiographs were equivocal, had open sutures based on computed tomography, thus establishing the diagnosis of deformational plagiocephaly in 69. Predisposing factors for this deformity included a strong positioning preference during early infancy (n = 67), torticollis (n = 10), prematurity (n = 6), and developmental delay (n = 2). Only two patients had true lambdoidal synostosis; in each case, this was associated with synostosis of the posterior sagittal suture and was managed effectively with cranial reconstructive surgery. Thirty-five patients with deformational plagiocephaly had a dramatic improvement in their cranial contour with positional therapy alone; 34 patients failed to improve and were treated with molding helmets. All but five children, each of whom was more than 6 months old at initial intervention (P &lt; .025), developed a normal or nearly normal head shape with these measures.
Conclusion. The vast majority of children with posterior plagiocephaly do not have true synostosis and can be effectively managed by nonsurgical means. The impact of positional preference on the development of this process is discussed.
Magnetic Resonance Imaging of Brain Anomalies in Fetal Alcohol Syndrome
Authors: Swayze Victor W. , Johnson Virginia P. , Hanson James W. , Piven Joseph , Sato Yutaka , Giedd Jay N. , Mosnik Diane , Andreasen Nancy C. 
Published: August 2004

Objective. Postmortem studies of fetuses, infants, and young children with fetal alcohol syndrome (FAS) have demonstrated a variety of severe central nervous system (CNS) anomalies. We undertook this magnetic resonance study (1) to assess the spectrum of CNS anomalies that occur in a clinical sample of typical patients with FAS who are medically stable; and (2) to examine the relationship between CNS and facial anomalies.Methodology. Magnetic resonance imaging was performed on a series of 10 patients (4 children, 3 adolescents, and 3 adults) who met criteria for FAS. We systematically evaluated each scan for brain anomalies and compared total brain tissue volume with that of healthy child, adolescent, and adult control subjects.Results. Six patients had some type of midline anomaly, ranging from partial to complete callosal agenesis (three patients) to hypoplastic corpus callosum (one patient), cavum septi pellucidi (three patients), and cavum vergae (two patients). These midline anomalies were associated with a greater number of facial anomalies. Other brain anomalies identified included micrencephaly, ventriculomegaly, and hypoplasia of the inferior olivary eminences.Conclusion. Patients with classic FAS have a high incidence of midline brain anomalies. This finding is consistent with the concept that the midline CNS is a developmental field that is particularly susceptible to the teratogenic effects of alcohol. Furthermore, patients with more severe facial dysmorphologic characteristics are more likely to have midline brain anomalies. In addition, we observed a high incidence of micrencephaly with a wide range of severity.
Meta-analyses of the Effectiveness of Intravenous Immune Globulin for Prevention and Treatment of Neonatal Sepsis
Authors: Jenson Hal B. , Pollock Brad H. 
Published: August 2004

Objective. To determine the effectiveness of intravenous immune globulin (IVIG) in the prevention and treatment of neonatal sepsis.Design. All published studies of IVIG for the prevention or treatment of neonatal sepsis were reviewed. Peer-reviewed, prospective, randomized trials with high merit were analyzed by two meta-analyses. The effect of prophylactic IVIG was evaluated by comparison of the numbers of cases of sepsis (bacteremia in the presence of systemic manifestations of sepsis), and of therapeutic IVIG by comparison of the numbers of deaths resulting from early-onset sepsis.Results. Meta-analysis of 4933 evaluable newborns in 12 studies of IVIG prophylaxis showed a statistically significant negative association with the incidence of sepsis in premature low birth weight newborns given IVIG shortly after birth (P = .0193, two-sided). The heterogeneity across these studies precluded estimation of a common odds ratio. Meta-analysis of 110 evaluable cases of neonatal sepsis in three studies of IVIG treatment of neonatal sepsis showed a significant decrease in the mortality rate for neonates with sepsis given IVIG (P = .007, two-sided). The common odds ratio was .173 (95% confidence interval = .031 to .735).Conclusions. Using conservative and objective outcome rating criteria, the addition of IVIG to standard therapies is of minimal but demonstrable benefit in preventing sepsis when administered prophylactically to premature low birth weight newborns, and of unequivocal benefit in preventing death when administered therapeutically for early-onset neonatal sepsis. The likelihood of newborns with sepsis living past the neonatal period was improved nearly sixfold when IVIG was administered in addition to standard therapies. neonatal sepsis, immune globulin.
Osteogenesis Imperfecta in Childhood: Impairment and Disability
Authors: Engelbert R. H. H. , van der Graaf Y. , van Empelen R. , Beemer F. A. , Helders P. J. M. 
Published: August 2004

Objective. To determine clinical characteristics in children with osteogenesis imperfecta (OI) regarding impairment (range of joint motion and muscle strength) and disability (functional skills) in relation to the different types of the disease, and to study the correlation between characteristics of impairment and disability.Methods. In a cross-sectional study 54 children with OI (OI type I: 24; OI type III: 15; OI type IV: 15), the range of joint motion, muscle strength, and functional ability were measured in a standardized way and analyzed statistically.Results. The range of joint motion in almost all joints differed significantly with respect to the different disease types. In OI type I patients, generalized hypermobility of the joints was present, without decrease in joint motion. In OI type III the extremities were severely maligned, especially the lower limbs. In type IV the upper and lower extremities were equally maligned. Muscle strength differed significantly with respect to the different types of OI. In type I patients, muscle strength was normal except for the periarticular hip muscles. In type III, especially in the lower extremities, muscle strength was severely decreased, with a muscular imbalance around the hip joint. In type IV, muscle strength was mainly decreased in the proximal muscles of the upper and lower extremities. In children ≤7.5 years of age, significant differences existed among the different disease types in functional skills regarding mobility. No significant difference was observed in self-care and social function, although the most severely affected children showed a tendency to score better with social function. Older children differed significantly concerning mobility and self-care items. In children ≤7.5 years old, a correlation was sometimes observed between impairment and disability items, although in older children a moderate to good correlation was always present (r &gt; .6).Conclusion. In OI, severity-related profiles exist, within the different subtypes of the disease, regarding range of joint motion, muscle strength, and functional skills. In younger children, impairment parameters do not sufficiently correlate for disability. Rehabilitation strategies in younger children should therefore focus on improvement of functional skills and not only on impairment parameters. osteogenesis imperfecta, pediatrics, muscle strength, range of joint motion, impairment, disability, functional outcome.