CONGENITAL HEART DISEASE, Issue 4 2008
Lisa Bergersen MD
ABSTRACT Objective., We sought to develop a method to adjust for case mix diversity and allow comparison of adverse outcome rates among practitioners in pediatric and congenital cardiac catheterization. Patients and Methods., A single institutional database that captured demographic and procedural data was used to identify patient and procedural characteristics associated with adverse events (AE) and any high severity event classified as preventable or possibly preventable (P/PP). Diagnostic and procedural risk groups were created and indicators of hemodynamic vulnerability were defined. Expected event rates by the practitioners adjusting for case mix were calculated. Standardized adverse event ratios (SAER), defined as the observed rate divided by the expected rate for each practitioner were calculated with 95% confidence intervals. Results., The database included 1727 hemodynamic (30%) and interventional (70%) cases performed by seven practitioners in 18 months. During 147 cases, at least one P/PP AE occurred; among the seven practitioners observed, event rates ranged from 3.2 to 14.2%. In multivariable analysis, risk factors for all P/PP events included highest procedure risk group (odds ratio [OR] 2.1 for group 2, and 2.8 for group 3, relative to group 1, P = .001 and P < .001, respectively) and weight less than 4 kg (OR 2.8, P < .001). High severity P/PP events occurred in 67 cases with rates ranging from 2.0 to 6.6% by the practitioners. For these events, risk factors included: highest procedure risk group (OR 4.5 for group 2, and 4.9 for group 3, both P < .001) and an indicator of hemodynamic vulnerability (OR 1.8, P = .026). For the seven practitioners, the SAER ranged from 0.41 to 1.32 for any P/PP AE and from 0.69 to 1.44 for P/PP high severity events. In this cohort, we did not identify any statistically significant performance differences. Conclusion., Despite wide variations in case mix complexity in pediatric and congenital cardiac catheterization, this study demonstrates a method for risk adjustment which allows equitable comparisons among practitioners at a single institution. [source]

Pathology of Chronic Constipation in Pediatric and Adult Coloproctology

HISTOPATHOLOGY, Issue 2 2006
J E Martin
No abstract is available for this article. [source]

5-Minute Pediatric Consult

JOURNAL OF PAEDIATRICS AND CHILD HEALTH, Issue 6 2003
MK Marks
No abstract is available for this article. [source]

Coping with chronic pain associated with cerebral palsy

OCCUPATIONAL THERAPY INTERNATIONAL, Issue 4 2006
Joyce M. Engel
Abstract Fifty-nine adults with cerebral palsy (CP) were administered, via in-person interviews, measures of pain intensity, pain-related disability, and psychological functioning, in addition to a measure of pain coping (Waldron/Varni Pediatric Pain Coping Inventory; PPCI). Regression analyses indicated that the PPCI scales made a nonsignificant contribution to the prediction of pain intensity, but did make a significant contribution to the prediction of psychological functioning when controlling for pain intensity. Only the PPCI Catastrophizing subscale made a significant independent contribution to the prediction of psychological functioning, and only the PPCI Seek Social Support subscale made a significant independent contribution to the prediction of pain-related disability. These findings support a link between coping and functioning among adults with CP, and suggest that catastrophizing responses and some aspects of support seeking may be maladaptive for coping with CP-related pain. Limitations of the study include a correlational design, a reliance on self-report data, and a small subject population. Experimental research is needed to determine if changes in coping lead to changes in psychological and physical functioning. Copyright © 2006 John Wiley & Sons, Ltd. [source]

International Society for Pediatric and Adolescent Diabetes (ISPAD)

PEDIATRIC DIABETES, Issue 1 2006
Article first published online: 20 FEB 200
No abstract is available for this article. [source]

Alcaligenes infection in cystic fibrosis,

PEDIATRIC PULMONOLOGY, Issue 2 2002
Kenneth Tan MBBS
Abstract The aim of this study was to investigate the effect of chronic Alcaligenes species infection of the respiratory tract on the clinical status of patients with cystic fibrosis. We conducted a retrospective case-controlled study. The microbiological records of all patients attending the Leeds Regional Pediatric and Adult Cystic Fibrosis Units from 1992,1999 were examined. Chronic Alcaligenes infection was defined as a positive sputum culture on at least three occasions over a 6-month period. These patients were compared with controls matched for age, gender, respiratory function, and Pseudomonas aeruginosa infection status. Respiratory function tests, anthropometric data, Shwachman-Kulczycki score, Northern chest x-ray score, intravenous and nebulized antibiotic treatment, and corticosteroid treatment were compared from 2 years before to 2 years after Alcaligenes infection. From a clinic population of 557, 13 (2.3%) fulfilled the criteria for chronic infection. The median age at acquisition of infection was 17.2 years (range, 6.5,33.6). There was no significant difference in the changes of percentage predicted values for FEV1, FVC, FEF25,75, or Shwachman-Kulczycki and Northern chest x-ray scores, or in weight, height, and body mass index z-scores between Alcaligenes -infected cases and controls. There was also no significant difference in the use of antibiotics (intravenous and nebulized) or corticosteroids (inhaled and oral). We conclude that in our clinic, chronic infection with Alcaligenes species was uncommon. Chronically infected patients showed no excess deterioration in clinical or pulmonary function status from 2 years before to 2 years after primary acquisition. Pediatr Pulmonol. 2002; 34:101,104. © 2002 Wiley-Liss, Inc. [source]

Pediatric living donor lobar lung transplantation

PEDIATRIC TRANSPLANTATION, Issue 7 2006
Stuart C. Sweet
Abstract:, Living donor lobar lung transplantation (LDLLT) was developed in order to mitigate the growing competition for deceased donor (DD) lungs and resultant increase in waiting list mortality. Because each of the two donor lobes serves as an entire lung for the recipient, donors who are taller than the recipient are preferred. Therefore LDLLT is particularly well suited for pediatric recipients for whom adults serve as donors. Although long-term outcomes after LDLLT reported by the Organ Procurement and Transplantation Network (OPTN) are worse compared with DD recipients, overall pediatric outcomes as well as single center reports from the most experienced programs are more promising. Particularly encouraging are the findings that bronchiolitis obliterans (OB) is less frequent or less severe in LDLLT recipients in comparison to DD recipients. Moreover, outcomes may be improved by careful selection of donors to ensure adequately sized donor lobes and minimization of infectious risks. Although no donor deaths have been reported, there is a moderate risk of significant short-term complications. Long-term follow-up has not been reported. The use of LDLLT has decreased in recent years, and the recent change by the OPTN to an urgency/benefit allocation system for DD lungs in patients 12 yr and older may further reduce the demand. Nonetheless, we anticipate that LDLLT will continue to be utilized in select circumstances, particularly in children under 12 where access to DD organs remains challenging. [source]

Long-term safety and efficacy of abatacept in children with juvenile idiopathic arthritis,

ARTHRITIS & RHEUMATISM, Issue 6 2010
Nicolino Ruperto
Objective We previously documented that abatacept was effective and safe in patients with juvenile idiopathic arthritis (JIA) who had not previously achieved a satisfactory clinical response with disease-modifying antirheumatic drugs or tumor necrosis factor blockade. Here, we report results from the long-term extension (LTE) phase of that study. Methods This report describes the long-term, open-label extension phase of a double-blind, randomized, controlled withdrawal trial in 190 patients with JIA ages 6,17 years. Children were treated with 10 mg/kg abatacept administered intravenously every 4 weeks, with or without methotrexate. Efficacy results were based on data derived from the 153 patients who entered the open-label LTE phase and reflect ,21 months (589 days) of treatment. Safety results include all available open-label data as of May 7, 2008. Results Of the 190 enrolled patients, 153 entered the LTE. By day 589, 90%, 88%, 75%, 57%, and 39% of patients treated with abatacept during the double-blind and LTE phases achieved responses according to the American College of Rheumatology (ACR) Pediatric 30 (Pedi 30), Pedi 50, Pedi 70, Pedi 90, and Pedi 100 criteria for improvement, respectively. Similar response rates were observed by day 589 among patients previously treated with placebo. Among patients who had not achieved an ACR Pedi 30 response at the end of the open-label lead-in phase and who proceeded directly into the LTE, 73%, 64%, 46%, 18%, and 5% achieved ACR Pedi 30, Pedi 50, Pedi 70, Pedi 90, and Pedi 100 responses, respectively, by day 589 of the LTE. No cases of tuberculosis and no malignancies were reported during the LTE. Pneumonia developed in 3 patients, and multiple sclerosis developed in 1 patient. Conclusion Abatacept provided clinically significant and durable efficacy in patients with JIA, including those who did not initially achieve an ACR Pedi 30 response during the initial 4-month open-label lead-in phase. [source]

Thalidomide dramatically improves the symptoms of early-onset Sarcoidosis/Blau syndrome: Its possible action and mechanism

ARTHRITIS & RHEUMATISM, Issue 1 2010
Kozo Yasui
Objective Early-onset sarcoidosis (EOS), which occurs in children younger than 5 years of age, is associated with granulomatous lesions and a sporadic genetic mutation of the nucleotide-binding oligomerization domain 2 that causes constitutive NF-,B activation. The symptoms of EOS can be uncontrollable, progressive, and associated with profound complications. However, appropriate therapy is still under investigation. The aim of this study was to assess the efficacy of thalidomide in patients with severe EOS, based on etiology supporting an initial role of NF-,B in activation of this disease. Methods Thalidomide was given to 2 patients with EOS (a 16-year-old girl and an 8-year-old boy) at an initial dosage of 2 mg/kg/day, and the dosage was increased if necessary. To elucidate the mechanism of the drug, peripheral blood monocytes were isolated from the patients and stimulated with cytokines (macrophage colony-stimulating factor, tumor necrosis factor ,, and interleukin-4), and their ability to form multinucleated giant cells (MGCs) and osteoclasts was measured. Results Both patients showed dramatic improvement of their clinical symptoms (alleviation of fever and optic nerve papillitis, achievement of a response according to the American College of Rheumatology Pediatric 50 and Pediatric 70 criteria) and laboratory findings. Monocytes from patients with EOS had a greater ability to survive and induce MGCs and osteoclasts than those from healthy control subjects. The formation of MGCs and osteoclasts was inhibited by the presence of thalidomide. Conclusion The ability of thalidomide to improve clinical symptoms and laboratory findings in patients with EOS indicates a central role for NF-,B activity in this disorder. Inhibition of IKK might be a pharmacologic action by which thalidomide down-regulates NF-,B signaling. Thalidomide may be an effective medication in patients with severe complications of EOS, including ocular involvement. [source]

Adult and Pediatric Emergency Department Sexually Transmitted Disease and HIV Screening: Programmatic Overview and Outcomes

ACADEMIC EMERGENCY MEDICINE, Issue 3 2007
Supriya D. Mehta PhD
Objectives: To measure the prevalence of gonorrhea, chlamydia, and human immunodeficiency virus (HIV) infection among emergency department (ED) patients who accept screening, and to assess treatment outcomes and risks for infection. Methods: Research staff offered voluntary testing for gonorrhea and chlamydia (by urine transcription-mediated amplification) and HIV (by enzyme immunoassay/Western blot of oral mucosal transudate) to ED patients. Pediatric (15,21 years) and adult (22,29 years) patients were eligible for gonorrhea and chlamydia testing; patients aged 15,54 years were eligible for HIV testing. The authors surveyed behavioral risks of patients accepting HIV testing. Results: From November 2003 to May 2004, 497 of 791 eligible pediatric patients (63%) and 1,000 of 2,180 eligible adult patients (46%) accepted screening for gonorrhea, chlamydia, and/or HIV. There were 41 patients infected with gonorrhea, chlamydia, or both among 380 pediatric patients (10.8%) and 11 of 233 adult patients (4.7%); 14 of 52 patients (27%) were treated presumptively by ED clinicians. Through study efforts, 33 of the 38 remaining patients were treated (90% overall treatment). Eight HIV infections were diagnosed: seven of 969 adult patients (0.7%) and one of 459 pediatric patients (0.2%); five HIV-infected patients (63%) received test results, and three (38%) attended an HIV clinic. Gonorrhea or chlamydia infection in pediatric patients was associated with multiple sex partners, same-sex intercourse, and suspicion of sexually transmitted diseases by the ED clinician. Conclusions: The high prevalence of gonorrhea and/or chlamydia infection among pediatric ED patients tested supports consideration of expanded screening. Targeted HIV screening with rapid tests merits exploration in the authors' ED, given the low-moderate numbers of patients identified through screening, receiving test results, and linked to care. [source]

The Long Road to Better ACHD Care

CONGENITAL HEART DISEASE, Issue 3 2010
Gary Webb MD
ABSTRACT The care of adult patients with congenital heart defects in the United States is spotty at best, and needs to improve greatly if the needs of these patients are to be met. The care of American children with congenital heart defects is generally excellent. Pediatric cardiac services are well established and well supported. The care of adults with congenital heart disease (CHD) is well established in only a few American centers. While there are an increasing number of clinics, they are generally poorly resourced with relatively few patients. If located in adult cardiology programs, they are usually minor players. If located in pediatric cardiac programs, they are usually minor players as well. Training programs for adult CHD (ACHD) caregivers are few, informal, and poorly funded. To improve the situation, we need perhaps 25 well-resourced and well-established regional ACHD centers in the United States. We need to stop the loss to care of CHD patients at risk of poor outcomes. We need to educate patients and families about the need for lifelong and skilled surveillance and care. We need to effect an orderly transfer from pediatric to adult care. We need to strengthen the human resource infrastructure of ACHD care through the training and hiring of healthcare professionals of a quality equivalent to those working in the pediatric care environment. We need to demonstrate that adult care is high quality care. We need more high-quality ACHD research. The ACHD community needs to establish its credibility with pediatric cardiac providers, adult cardiology groups, with governments, with professional organizations, and with research funding agencies. Accordingly, there is a need for strong political action on behalf of American ACHD patients. This must be led by patients and families. These efforts should be supported by pediatric cardiologists and children's hospitals, as well as by national professional organizations, governments, and health insurance companies. The goal of this political action should be to see that ACHD patients can receive high-quality lifelong surveillance, that we lose fewer patients to care, and that the staff and other services needed are available nationwide. [source]

A Risk Adjusted Method for Comparing Adverse Outcomes among Practitioners in Pediatric and Congenital Cardiac Catheterization

Thyroid fine-needle aspiration biopsy in children and adolescents: Experience with 218 aspirates

DIAGNOSTIC CYTOPATHOLOGY, Issue 4 2005
Mojghan Amrikachi M.D.
Abstract To evaluate the role of fine-needle aspiration (FNA) biopsy of thyroid nodules in pediatric and adolescent patients, the cytology reports of 218 thyroid FNA biopsies performed on children and adolescents ranging from10 to 21 yr of age were reviewed. The cytology diagnoses were categorized into four groups: unsatisfactory, benign, suspicious, and malignant. One hundred nineteen (54%) of the aspirates were diagnosed as "benign," 20 (9%) were diagnosed as suspicious for malignancy; and 17 (8%) were diagnosed as malignant. Sixty-two (28%) of the aspirates were read as unsatisfactory for interpretation. Sensitivity of thyroid FNA in diagnosing thyroid malignancy relative to final histological diagnoses was 100%, and specificity was 65%. FNA of thyroid nodules in the pediatric and adolescent population is comparably as sensitive and specific as in the adult population. The acceptance of this procedure in the routine evaluation of young patients' thyroid nodules should reduce the number of unnecessary surgeries for benign thyroid disease. Diagn. Cytopathol. 2005;32:189,192. © 2005 Wiley-Liss, Inc. [source]

Pediatric Emergency Medicine Education in Emergency Medicine Training Programs

ACADEMIC EMERGENCY MEDICINE, Issue 7 2000
Vincent P Tamariz MD
Abstract. Background: The educational goal of emergency medicine (EM) programs has been to prepare its graduates to provide care for a diverse range of patients and presentations, including pediatric patients. Objective: To evaluate the methods used to teach pediatric emergency medicine (PEM) to EM residents. Methods: A written questionnaire was distributed to 118 EM programs. Demographic data were requested concerning the type of residency program, number of residents, required pediatric rotations, elective pediatric rotations, type of hospital and settings in which pediatric patients are seen, and procedures performed. Information was also requested on the educational methods used, proctoring EM received, and any formal curriculum used. Results: Ninety-four percent (111/118) of the programs responded, with 80% of surveys completed by the residency director. Proctoring was primarily performed by PEM attendings and general EM attendings. Formal means of PEM education most often included the EM core curriculum (94%), journal club (95%), EM grand rounds (94%), and EM morbidity and mortality (M&M) conference (91%). Rotations and electives most often included the pediatric intensive care unit (PICU) and the emergency department (ED) (general and pediatric). Conclusions: Emergency medicine residents are exposed to PEM primarily by rotating through a general ED, the PED, and the PICU, being proctored by PEM and EM attendings and attending EM lectures and EM M&M conferences. Areas that may merit further attention for pediatric emergency training include experience in areas of neonatal resuscitation, pediatric M&M, and specific pediatric electives. This survey highlights the need to describe current educational strategies as a first step to assess perceived effectiveness. [source]

Imbalances of chromosome arm 1p in pediatric and adult germ cell tumors are caused by true allelic loss: A combined comparative genomic hybridization and microsatellite analysis

GENES, CHROMOSOMES AND CANCER, Issue 11 2006
Susanne Zahn
Previous studies on childhood germ cell tumors (GCTs) report highly variable frequencies of losses at chromosome arm 1p. Since deletions at 1p portend a poor prognosis in other embryonal tumors, this study aims to clarify the question of the frequency of true allelic loss at 1p and whether it constitutes a prognostic parameter. We analyzed 13 GCTs from different gonadal and extragonadal sites of children (4 teratomas, 9 malignant GCTs) and 18 GCTs of adolescents and adults (3 teratomas; 15 malignant GCTs) using automated microsatellite analysis with 23 polymorphic markers and chromosomal "high resolution" comparative genomic hybridization (HR-CGH). With this combined approach, we detected loss of heterozygosity (LOH) at 1p in 8/9 childhood malignant GCTs with concordant data from HR-CGH and microsatellite analyses. In contrast, LOH at 1p was not detected in childhood teratomas (0/4) and constituted a rare event in GCTs of adolescence and adulthood (3/18). The commonly deleted region was located at distal 1p36-pter, with a proximal boundary between the markers D1S450 and D1S2870. These data unequivocally demonstrate that deletion at 1p is common in childhood GCTs and results in allelic loss. This observation argues for the presence of a classical tumor suppressor at distal 1p. Considering the high frequency of LOH at 1p and the overall favorable prognosis of childhood GCTs, a prognostic impact of LOH at 1p in childhood GCTs appears unlikely. However, since two postpubertal tumors with LOH at 1p progressed, a prognostic relevance in this age group seems possible, warranting a prospective evaluation. © 2006 Wiley-Liss, Inc. [source]

Inflammatory bowel disease in young people: The case for transitional clinics

INFLAMMATORY BOWEL DISEASES, Issue 6 2010
J. Goodhand MRCP
Abstract Background: The incidence of inflammatory bowel disease (IBD) is increasing among adolescents. In all, 25% of patients are diagnosed before the age of 16, when they are traditionally transferred from the pediatric to the adult service. Methods: We conducted a retrospective case-controlled study to characterize patients treated in a novel transitional adolescent,young adult IBD clinic. This compared disease extent, radiation exposure, therapeutic strategy, and requirement for surgery in 100 adolescents with controls from our adult IBD clinic matched for disease duration. Results: The median (range) ages for the adolescent and adult population was 19 (16,28) and 43 (24,84), with a median age at diagnosis of 15 (3,26) and 39 (13,82) respectively (P < 0.001). Crohn's disease was significantly more common in the adolescents. Disease distribution was ileocolonic in 69% of adolescents and 28% of adults, restricted to the ileum in 20% of adolescents and 47% of adults, and colonic only in 11% and 22%, respectively. Upper gastrointestinal involvement occurred in 23% of adolescents, but was not seen in adults (P < 0.01). Total ulcerative colitis was seen in 67% of adolescents and 44% of adults (P < 0.01). Contrary to previous data adolescents did not receive more ionizing radiation than adults. Requirement for immunosuppressive therapy was higher in the adolescent group (53% versus 31%, respectively, P < 0.01). Likewise, 20% of adolescents had required biological therapy compared to only 8% in the adult cohort (P < 0.05). Conclusions: Gastroenterologists should recognize that IBD is more complex when presenting in adolescence and our data support the creation of specific adolescent transitional clinics. Inflamm Bowel Dis 2009 [source]

Strong expression of IGF1R in pediatric gastrointestinal stromal tumors without IGF1R genomic amplification,

INTERNATIONAL JOURNAL OF CANCER, Issue 11 2010
Katherine A. Janeway
Abstract Wildtype (WT) gastrointestinal stromal tumors (GISTs), lacking mutations in KIT or PDGFRA, represent 85% of GISTs in pediatric patients. Treatment options for pediatric WT GIST are limited. Recently, expression profiling of a limited number of pediatric and adult WT GISTs and more in depth study of a single pediatric WT GIST implicated the insulin-like growth factor 1 receptor (IGF1R) as a potential therapeutic target in pediatric WT GIST. We performed immunoblotting, SNP and FISH studies to determine the extent of expression, biochemical activation and genomic amplification of IGF1R in a larger number of pediatric WT GISTs. Pediatric WT GISTs expressed IGF1R strongly, whereas typical adult KIT mutant GISTs did not. IGF1R gene amplification was not detected in pediatric WT GISTs, and some KIT -mutant GISTs had IGF1R gene deletion due to monosomy 15. Despite the absence of apparent genomic activation mechanisms accounting for overexpression, clinical study of IGF1R-directed therapies in pediatric WT GIST is warranted. [source]

Risk of cancer among children of cancer patients,a nationwide study in Finland

INTERNATIONAL JOURNAL OF CANCER, Issue 5 2010
Laura-Maria S. Madanat-Harjuoja
Abstract Cancer treatments have the potential to cause germline mutations that might increase the risk of cancer in the offspring of former cancer patients. This risk was evaluated in a population-based study of early onset cancer patients in Finland. Using the nationwide registry data, 26,331 children of pediatric and early onset cancer patients (diagnosed under age 35 between 1953 and 2004) were compared to 58,155 children of siblings. Cancer occurrence among the children was determined by linkage with the cancer registry, and the standardized incidence ratios (SIRs) were calculated comparing the observed number of cancers with that expected, based on rates in the general population of Finland. Among the 9,877 children born after their parent's diagnosis, cancer risk was increased (SIR 1.67; 95% CI 1.29,2.12). However, after removing those with hereditary cancer syndromes, this increase disappeared (SIR 1.03; 95% CI 0.74,1.40). The overall risk of cancer among the offspring of siblings (SIR 1.07; 95% CI 0.94,1.21) was the same as among the offspring of the patients with nonhereditary cancer. Risk of cancer in offspring, born before their parents cancer diagnosis, was elevated (SIR 1.37, 95% CI 1.20-1.54), but removing hereditary syndromes resulted in a diminished and nonsignificant association (SIR 1.08, 95% CI 0.93-1.25). This study shows that offspring of cancer patients are not at an increased risk of cancer except when the patient has a cancer-predisposing syndrome. These findings are directly relevant to counseling cancer survivors with regard to family planning. [source]

Supraventricular Arrhythmias in Children and Young Adults with Implantable Cardioverter Defibrillators

JOURNAL OF CARDIOVASCULAR ELECTROPHYSIOLOGY, Issue 10 2001
BARRY A. LOVE M.D.
SVT in Pediatric ICD Recipients.Introduction: Rapidly conducted supraventricular tachycardias (SVTs) can lead to inappropriate device therapy in implantable cardioverter defibrillator (ICD) patients. We sought to determine the incidence of SVTs and the occurrence of inappropriate ICD therapy due to SVT in a pediatric and young adult population. Methods and Results: We undertook a retrospective review of clinical course, Holter monitoring, and ICD interrogations of patients receiving ICD follow-up at our institution between March 1992 and December 1999. Of 81 new ICD implantations, 54 eligible patients (median age 16.5 years, range 1 to 48) were identified. Implantation indications included syncope and/or spontaneous/inducible ventricular arrhythmia with congenital heart disease (30), long QT syndrome (9), structurally normal heart (ventricular tachycardia/ventricular fibrillation [VT/VF]) (7), and cardiomyopathies (7). Sixteen patients (30%) received a dual-chamber ICD. SVT was recognized in 16 patients, with 12 of 16 having inducible or spontaneous atrial tachycardias. Eighteen patients (33%) received , 1 appropriate shock(s) for VT/VF; 8 patients (15%) received inappropriate therapy for SVT. Therapies were altered after an inappropriate shock by increasing the detection time or rate and/or increasing beta-blocker dosage. No single-chamber ICD was initially programmed with detection enhancements, such as sudden onset, rate stability, or QRS discriminators. Only one dual-chamber defibrillator was programmed with an atrial discrimination algorithm. Appropriate ICD therapy was not withheld due to detection parameters or SVT discrimination programming. Conclusion: SVT in children and young adults with ICDs is common. Inappropriate shocks due to SVT can be curtailed even without dual-chamber devices or specific SVT discrimination algorithms. [source]

Why Bystanders Decline Telephone Cardiac Resuscitation Advice

ACADEMIC EMERGENCY MEDICINE, Issue 9 2010
Fabrice Dami MD
Abstract Objectives:, The aim of this study was to evaluate the rate and reason for refusal of telephone-based cardiopulmonary resuscitation (CPR) instruction by bystanders after the implementation of the dispatch center's systematic telephone CPR protocol. Methods:, Over a 15-month period the authors prospectively collected all case records from the emergency medical services (EMS) dispatch center when CPR had been proposed to the bystander calling in and recorded the reason for declining or not performing that the bystander spontaneously mentioned. All pediatric and adult traumatic and nontraumatic cases were included. Situations when resuscitation had been spontaneously initiated by bystanders were excluded. Results:, During the study period, dispatchers proposed CPR on 264 occasions: 232 adult nontraumatic cases, 17 adult traumatic cases, and 15 pediatric (traumatic and nontraumatic) cases. The proposal was accepted in 163 cases (61.7%, 95% confidence interval [CI] = 54.6% to 66.5%), and CPR was eventually performed in 134 cases (51%, 95% CI = 43.2% to 55.3%). In 35 of the cases where resuscitation was not carried out, the condition of the patient or conditions at the scene made this decision medically appropriate. Of the remaining 95 cases, 55 were due to physical limitations of the caller, and 33 were due to emotional distress. Conclusions:, The telephone CPR acceptance rate of 62% in this study is comparable to those of other similar studies. Because bystanders' physical condition is one of the keys to success, the rate may not improve as the population ages. ACADEMIC EMERGENCY MEDICINE 2010; 17:1012,1015 © 2010 by the Society for Academic Emergency Medicine [source]

Pharmacoepidemiologic investigation of a clonazepam-valproic acid interaction by mixed effect modeling using routine clinical pharmacokinetic data in Japanese patients

JOURNAL OF CLINICAL PHARMACY & THERAPEUTICS, Issue 6 2003
E. Yukawa
Summary Non-linear Mixed Effects Modeling (NONMEM) was used to estimate the effects of clonazepam,valproic acid interaction on clearance values using 576 serum levels collected from 317 pediatric and adult epileptic patients (age range, 0·3,32·6 years) during their clinical routine care. Patients received the administration of clonazepam and/or valproic acid. The final model describing clonazepam clearance was CL = 144·0 TBW,0·172 1·14VPA, where CL is total body clearance (mL/kg/h); TBW is total body weight (kg); VPA = 1 for concomitant administration of valproic acid and VPA = zero otherwise. The final model describing valproic acid clearance was CL (mL/kg/h) = 17·2 TBW,0·264 DOSE0·159 0·821CZP 0·896GEN, where DOSE is the daily dose of valproic acid (mg/kg/day); CZP = 1 for concomitant administration of clonazepam and CZP = zero otherwise; GEN = 1 for female and GEN = zero otherwise. Concomitant administration of clonazepam and valproic acid resulted in a 14% increase in clonazepam clearance, and a 17·9% decrease in valproic acid clearance. [source]

Evidence-based algorithms for diagnosing and treating ventilator-associated pneumonia,

JOURNAL OF HOSPITAL MEDICINE, Issue 5 2008
Richard J. Wall MD
Abstract BACKGROUND: Ventilator-associated pneumonia (VAP) is widely recognized as a serious and common complication associated with high morbidity and high costs. Given the complexity of caring for heterogeneous populations in the intensive care unit (ICU), however, there is still uncertainty regarding how to diagnose and manage VAP. OBJECTIVE: We recently conducted a national collaborative aimed at reducing health care,associated infections in ICUs of hospitals operated by the Hospital Corporation of America (HCA). As part of this collaborative, we developed algorithms for diagnosing and treating VAP in mechanically ventilated patients. In the current article, we (1) review the current evidence for diagnosing VAP, (2) describe our approach for developing these algorithms, and (3) illustrate the utility of the diagnostic algorithms using clinical teaching cases. DESIGN: This was a descriptive study, using data from a national collaborative focused on reducing VAP and catheter-related bloodstream infections. SETTING: The setting of the study was 110 ICUs at 61 HCA hospitals. INTERVENTION: None. MEASUREMENTS AND RESULTS: We assembled an interdisciplinary team that included infectious disease specialists, intensivists, hospitalists, statisticians, critical care nurses, and pharmacists. After reviewing published studies and the Centers for Disease Control and Prevention VAP guidelines, the team iteratively discussed the evidence, achieved consensus, and ultimately developed these practical algorithms. The diagnostic algorithms address infant, pediatric, immunocompromised, and adult ICU patients. CONCLUSIONS: We present practical algorithms for diagnosing and managing VAP in mechanically ventilated patients. These algorithms may provide evidence-based real-time guidance to clinicians seeking a standardized approach to diagnosing and managing this challenging problem. Journal of Hospital Medicine 2008;3:409,422. © 2008 Society of Hospital Medicine. [source]

Magnetic resonance and computed tomographic evaluation of congenital heart disease

JOURNAL OF MAGNETIC RESONANCE IMAGING, Issue 6 2004
Lawrence M. Boxt MD
Abstract Magnetic resonance imaging (MRI) and contrast-enhanced computed tomography (CT) provide noninvasive visualization of morphologic changes in pediatric and adult patients with congenital heart disease, as well as the functional changes caused by the underlying morphologic abnormalities. Clinical experience with MRI is richer than that with fast CT, but CT appears to provide accurate and high-quality imagery for diagnosis. The two modalities may be complementary. That is, intracardiac anatomy is so well depicted by MRI, and CT provides exquisite images of the great vessels. Furthermore, in adult patients, MR and CT are helpful in demonstrating and quantitating physiologic changes superimposed by acquired cardiovascular disease on the underlying congenital malformations. Using MRI, spin echo acquisitions provide the image data for evaluation of morphologic changes, and gradient reversal techniques add functional and flow data to complement morphologic changes. Contrast-enhanced electrocardiographic (ECG)-gated multidetector and electron beam CT examination provide morphologic information and may be used as a data set for off-line functional quantitation. J. Magn. Reson. Imaging 2004;19:827,847. © 2004 Wiley-Liss, Inc. [source]

Pediatric Travel Consultation in an Integrated Clinic

JOURNAL OF TRAVEL MEDICINE, Issue 1 2001
John C. Christenson
Background: In May 1997, a pediatric travel service was created within a larger integrated University-County Health Department international travel clinic. The purpose of the service was to further enhance the travel advice and care provided to children and their parents or guardians. The current study was designed to describe the care of children in this setting and to compare the care of children seen in the Pediatric Travel Service with that of children seen by other providers. Methods: All pediatric patients (defined as individuals , 18 years of age) receiving care in the travel clinic were considered candidates for inclusion in the analysis. Patients seen by the Pediatric Travel Service were compared to those seen by other staff members in the travel clinic (referred to as Regular Clinic). The following information was noted: basic demographic data, medical history including allergies, prior immunization records, intended place and duration of travel, and immunizations and medications prescribed at the time of visit. Travel advice covering water and food precautions, preventive measures against insect bites, injury prevention, malaria prevention, prevention of parasitic infections, and environmental-related problems was provided to all patients in both groups when necessary. Results: Between May 1997 and December 1999, 287 pediatric age individuals were given pretravel care by the Pediatric Travel Service (median age, 6 years; range, 1 month-18 years). During the same time period, 722 pediatric age travelers (median age, 14 years; range, 8 months-18 years) were evaluated in the Regular Clinic by other staff members. Travel destinations most commonly traveled by both groups in descending order were: Africa, Central America and Mexico, South America, and Southeast Asia. When compared to travelers seen in the Regular Clinic, individuals in the Pediatric Travel Service group were more likely to travel for humanitarian work, and for parental work relocation. Persons in the Regular Clinic were more likely to travel to Mexico and Central America. They were also more likely to travel on vacation and for missionary work or study. Hepatitis B and tetanus-diphtheria booster vaccinations were given more frequently to travelers seen in the Regular Clinic. Also, ciprofloxacin and antimotility agents were more commonly prescribed in this group. No differences were noted in the duration of travel or in the time interval between clinic visit and departure. Conclusions: While general travel advice was considered to be similar in both clinic groups, some differences were observed in the frequency of administration of certain vaccines and prescriptions of medications. These differences were likely due to a difference in age in the two study groups. The high volume and success of the clinic suggest that integrated pediatric and adult travel services in a coordinated setting can be effective. [source]

Hepatic venous outflow obstruction in pediatric living donor liver transplantation using left-sided lobe grafts: Kyoto university experience,

LIVER TRANSPLANTATION, Issue 10 2010
Seisuke Sakamoto
The goals of this study were to evaluate the incidence of hepatic venous outflow obstruction (HVOO) in pediatric patients after living donor liver transplantation (LDLT) using left-sided lobe grafts and to assess the therapeutic modalities used for the treatment of this complication at a single center. Four hundred thirteen primary LDLT procedures were performed with left-sided lobe grafts between 1996 and 2006. All transplants identified with HVOO from a cohort of 380 grafts with survival greater than 90 days were evaluated with respect to the patient demographics, therapeutic intervention, recurrence, and outcome. Seventeen cases (4.5%) were identified with HVOO. Eight patients experienced recurrence after the initial balloon venoplasty. Two patients finally required stent placement after they experienced recurrence shortly after the initial balloon venoplasty. A univariate analysis revealed that a smaller recipient-to-donor body weight ratio and the use of reduced grafts were statistically significant risk factors. The cases with grafts with multiple hepatic veins had a higher incidence of HVOO. In conclusion, the necessity of repeated balloon venoplasty and stent placement was related to poor graft survival. Therefore, the prevention of HVOO should be a high priority in LDLT. When grafts with multiple hepatic veins and/or significant donor-recipient size mismatching are encountered, the use of a patch graft is recommended. Stent placement should be carefully considered because of the absence of data on the long-term patency of stents and stent-related complications. New stenting devices, such as drug-eluting and biodegradable stents, may be promising for the management of HVOO. Liver Transpl 16:1207,1214, 2010. © 2010 AASLD. [source]

ABO-incompatible deceased donor liver transplantation in the United States: A national registry analysis,

LIVER TRANSPLANTATION, Issue 8 2009
Zoe A. Stewart
In the United States, ABO-incompatible liver transplantation (ILT) is limited to emergent situations when ABO-compatible liver transplantation (CLT) is unavailable. We analyzed the United Network for Organ Sharing database of ILT performed from 1990-2006 to assess ILT outcomes for infant (0-1 years; N = 156), pediatric (2-17 years; N = 170), and adult (> 17 years; N = 667) patients. Since 2000, the number of ILT has decreased annually, and there has been decreased use of blood type B donors and increased use of blood type A donors. Furthermore, ILT graft survival has improved for all age groups in recent years, beyond the improved graft survival attributable to era effect based on comparison to respective age group CLT. On matched control analysis, graft survival was significantly worse for adult ILT as compared to adult CLT. However, infant and pediatric ILTs did not have worse graft survival versus age-matched CLT. Adjusted analyses identified age-specific characteristics impacting ILT graft loss. For infants, transplant after 2000 and donor age < 9 years were associated with reduced risk of ILT graft loss. For pediatric patients, female recipient sex and donor age > 50 years were associated with increased risk of ILT graft loss. For adults, life support, repeat transplant, split grafts, and hepatocellular carcinoma were associated with increased risk of ILT graft loss. The current study identifies important trends in ILT in the United States in the modern immunosuppression era, as well as specific recipient, donor, and graft characteristics impacting ILT graft survival that could be utilized to guide ILT organ allocation in exigent circumstances. Liver Transpl 15:883,893, 2009. © 2009 AASLD. [source]

Genetics and Asthma Disease Susceptibility in the US Latino Population

MOUNT SINAI JOURNAL OF MEDICINE: A JOURNAL OF PERSONALIZED AND TRANSLATIONAL MEDICINE, Issue 2 2010
Joan Reibman MD
Abstract The US Latino population is heterogeneous with diversity in environmental exposures and socioeconomic status. Moreover, the US Hispanic population derives from numerous countries previously under Spanish rule, and many Hispanics have complex proportions of European, Native American, and African ancestry. Disparities in asthma severity and control are due to complex interactions between environmental exposures, socioeconomic factors, and genetic variations. In addition, diseases within the Latino community may also differ by country of origin. Although US Census data show low asthma rates in the Hispanic population as a whole, there is a lot of variability in the prevalence and morbidity of asthma, with a prevalence of 5.0% in Mexican Americans versus 17.0% in Puerto Ricans. The diversity and population admixture make the study of the genetics of asthma complex in Latino populations. However, an understanding of the genetics of asthma in all populations, including the Latino population, can enhance risk identification, help us to target pharmacological therapy, and guide environmental regulations, all of which can promote a reduction in health disparities. The inclusion of markers of ancestral diversity and the incorporation of techniques to adjust for stratification now make these studies feasible in complex populations, including the Latino population. To date, studies using linkage analyses, genome-wide associations, or candidate gene analyses have identified an association of asthma or asthma-related phenotypes with candidate genes, including interleukin 13, ,-2 adrenergic receptor, a disintegrin and metalloproteinase 33, orosomucoid 1-like 3, and thymic stromal lymphopoietin. As reviewed here, although these genes have been identified in diverse populations, limited studies have been performed in Latino populations, and they have had variable replication. There is a need for the development of registries with well-phenotyped pediatric and adult Latino populations and subgroups for inclusion in the rapidly expanding field of genetic studies, and these studies need to be used to reduce health disparities. Mt Sinai J Med 77:140,148, 2010. © 2010 Mount Sinai School of Medicine [source]

35 Electrogastrography in healthy participants: comparison of children and adults

NEUROGASTROENTEROLOGY & MOTILITY, Issue 6 2006
CA FRIESEN
The current study examined whether electrogastrogram (EGG) patterns differ between children/adolescents and adults, including whether EGG recordings obtained from healthy children would be considered normal by standards established for adults. Twenty-eight healthy children (54% females; ages 8,17, M = 12.4 years) were evaluated and compared to 15 healthy adults. EGGs were recorded for 30 min in the fasting state and for 1 h following a standard meal. For both pediatric and adult participants, there was a significant increase in both the dominant frequency and the dominant power from the pre- to the post , prandial period (p < 0.001 for each). There was a significant post-prandial increase in the %normal slow waves in pediatric participants only (81.5 vs. 89.0% vs. p < 0.001). Children demonstrated a significantly lower mean fasting %normal slow waves (81.5% vs. 94.2%) and a significantly greater fasting % tachygastria (8.9% vs. 2.3%) than did adults. Other parameters did not differ. Using adult standards, the %normal slow waves were ,70% of recording time in 96% children in the fasting state and in 100% in the postprandial period. A postprandial power increase was seen in 89% of the children. In conclusion, while adults should not be used as controls in pediatric studies of EGG, our data would indicate that American Motility Society (AMS) consensus adult criteria for a normal EGG are appropriate to apply to children and adolescents when utilizing methodology and meal challenge similar to that used to establish the adult norms. [source]

Electrophysiologic Characteristics and Radiofrequency Catheter Ablation in Children with Wolff-Parkinson-White Syndrome

PACING AND CLINICAL ELECTROPHYSIOLOGY, Issue 5 2006
PI-CHANG LEE
Background: The majority of cardiac arrhythmias in children are supraventricular tachycardia, which is mainly related to an accessory pathway (AP)-mediated reentry mechanism. The investigation for Wolff-Parkinson-White (WPW) syndrome in adults is numerous, but there is only limited information for children. This study was designed to evaluate the specific electrophysiologic characteristics and the outcome of radiofrequency (RF) catheter ablation in children with WPW syndrome. Methods: From December 1989 to August 2005, a total of 142 children and 1,219 adults with atrioventricular reentrant tachycardia (AVRT) who underwent ablation at our institution were included. We compared the clinical and electrophysiologic characteristics between children and adults with WPW syndrome. Results: The incidence of intermittent WPW syndrome was higher in children (7% vs 3%, P=0.025). There was a higher occurrence of rapid atrial pacing needed to induce tachycardia in children (67% vs 53%, P=0.02). However, atrial fibrillation (AF) occurred more commonly in adult patients (28% vs 16%, P = 0.003). The pediatric patients had a higher incidence of multiple pathways (5% vs 1%, P < 0.001). Both the onset and duration of symptoms were significantly shorter in the pediatric patients. The antegrade 1:1 AP conduction pacing cycle length (CL) and antegrade AP effective refractory period (ERP) in children were much shorter than those in adults with manifest WPW syndrome. Furthermore, the retrograde 1:1 AP conduction pacing CL and retrograde AP ERP in children were also shorter than those in adults. The antegrade 1:1 atrioventricular (AV) node conduction pacing CL, AV nodal ERP, and the CL of the tachycardia were all shorter in the pediatric patients. Conclusion: This study demonstrated the difference in the electrophysiologic characteristics of APs and the AV node between pediatric and adult patients. RF catheter ablation was a safe and effective method to manage children with WPW syndrome. [source]