Clinical scoring system for Lumbar puncture in infants.
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Humans↗
Biomedical subjects
C DeAngelis
Publications and source records attributed to C DeAngelis.
Re-evaluating the cost of outpatient cancer chemotherapy.
Chemotherapy for common malignant tumours has historically been considered relatively expensive. An examination of costs at the Toronto-Bayview Regional Cancer Centre and Sunnybrook Medical Centre, Toronto, suggests that this perception is not accurate. The cost of chemotherapeutic agents administered on an outpatient basis over 4 to 6 months in established drug protocols ranged from $260 to $5374 (mean $2224). The total cost of outpatient administration was estimated to be $152.53 per dose, compared with $185.39 for inpatient administration of the same protocol, a difference of 22%. The difference was predominantly due to a higher allocated per-diem charge at the medical centre. The results indicate that outpatient administration reduces the overall cost of chemotherapy.
Ambulatory Care↗
Prescription medications in infancy and early childhood.
The prescription medication exposures of a cohort of 222 children during their first five years of life were investigated. Excluding the three outliers, the cohort received 1852 medications (average per child, 8.46; mode, six; range, 0 to 37) during 1358 (23%) of the total 6017 visits made in five years. The greatest number of medications were administered or prescribed between 7 and 12 months of age. The majority (62%) of the medications over five years were oral preparations, and 87% were prescribed for two weeks or less. Antibacterials, bronchodilators, and antifungal-anti-yeasts accounted for 80% of the 1852 medication courses. One third of all medications were for ampicillin or amoxicillin. High medication recipients were likely to have chronic conditions, especially recurrent otitis media and/or asthma, and were likely to be high users of our health facility.
Age Factors↗
Phase I and pharmacokinetic study of high volume intraperitoneal aclacinomycin-A (Aclarubicin).
Aclacinomycin-A (Aclarubicin) is a relatively new anthracycline antibiotic with potential activity against ovarian cancer. Eight patients with various malignancies (4 ovary, 1 breast and ovary, 1 breast, 1 colon, 1 leiomyosarcoma) and intraperitoneal disease were treated in a Phase I trial with escalating doses of intraperitoneal Aclacinomycin. Drug treatments were administered through a peritoneal catheter in a 2 liter fluid volume (1.5% Dianeal). Seventeen cycles were administered with doses ranging from 25 to 75 mg of Aclacinomycin. Pharmacokinetic studies were carried out in 7 patients. Although high concentrations of Aclacinomycin could be obtained in the peritoneal cavity no drug was detected in the plasma. The major dose-limiting toxicity was chemical peritonitis. Two patients had reduction in the amount of ascites. The recommended dose for Phase II trials is Aclacinomycin 50 mg in 2 liters given every 2 weeks.
Aclarubicin↗
Medical malpractice litigation: does it augment or impede quality care?
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Costs and Cost Analysis↗
Outpatient radiographic exposure in the first five years of life.
Young children receive a variety of diagnostic radiographs over time. In some cases the exposure to radiation may be unwarranted because the films may yield confusing results, or may also need to be repeated because of poor technical quality. Even when the results are clearly negative, the subsequent treatment may proceed as if the film had been positive because of the child's clinical condition. The cumulative effect of such low-dose radiation on infants and children over time is unknown. The number and types of outpatient radiographs received by a cohort of poor children from a hospital-based continuity clinic during their first 5 years of life were reviewed. Also noted were the reason for obtaining the film, whether it was positive for that reason or another, whether the child had a chronic condition that prompted the use of radiograph, and the child's sex, race, and age when the film was obtained. Of the 218 children, 132 (60.6%) received 349 sets of films in their first 5 years. There was no difference in the number of films by race or sex. Chest and posttrauma bone or joint films accounted for 315 sets of films or 90.3% of the total. Overall, 25.8% of the 267 chest films were positive; this varied by age. Only 15% of the chest films were positive in the first year compared with 29 to 49% in the second through fifth years (p less than 0.001). Cough was the respiratory symptom most reliably associated with a positive chest film, both for the cohort (p less than 0.0001) and for children in the first year of life (p less than 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)
Age Factors↗
Health services use by children enrolled in a hospital-based primary care clinic: a longitudinal perspective.
The use of a hospital-based primary care clinic for health maintenance and illness care and use of the emergency room were monitored for 3 years for 293 children who had been enrolled in the clinic as infants. Infrequent users of one facet of care were infrequent users of other facets of care, and they remained so for all 3 years. The same trends were noted for frequent users. Children who used the clinic for health maintenance infrequently were more likely to have registered in the clinic after 2 months of age and to demonstrate consistently infrequent use throughout the 3 years. Children who used the clinic for illness care infrequently were more likely to have at least two siblings and to demonstrate consistently infrequent use. Children who used the emergency room infrequently were likely to have been consistently infrequent users for emergencies and illness throughout the 3 years. Conversely, those who used the clinic frequently for health maintenance were more likely to have registered before 1 month of age, to have multiple chronic conditions, and to demonstrate consistently frequent use for maintenance throughout the 3 years. Frequent users for illness care were more likely to have none or one sibling, multiple chronic conditions, and to demonstrate consistently frequent use for illnesses. Finally, children who used the emergency room frequently were likely to have multiple chronic conditions and to demonstrate sustained frequent use throughout the 3 years. These results suggest that patterns of use are established as early as the first year of life.
Ambulatory Care Facilities↗
A comprehensive school health initiative.
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Child↗
Degradation kinetics of imipenem in normal saline and in human serum.
The stability of imipenem in 0.9% sodium chloride and in human serum was measured at controlled temperatures over time. The degradation was characterized by a first-order process and was consistent with an apparent hydrolysis reaction.
Drug Stability↗
Capitation reimbursement for pediatric primary care.
A feasibility analysis of capitation reimbursement for a primarily Medicaid population in The Johns Hopkins Pediatric Primary Care Clinic was conducted. The utilization of all inpatient and outpatient care of 2,261 patients was monitored for a 6-month period. As a result, per capita rates based on charges were determined for each group of patients according to type of insurance. Blue Cross and private insurance patients had capitation rates three times that of the Medicaid patients and over ten times that of self-pay patients This variation in utilization was attributed to the selection of enrollees, the morbidity of the population, and the varying services covered by payor group. Administrative issues regarding establishing a pediatric health maintenance organization are also discussed. Close supervision of house staff in treating patients, including admissions, length of stay, and specialty referral is of utmost importance in containing costs in this clinic setting.
Capitation Fee↗
Assignment of follow-up appointments from an emergency room by pediatric residents.
A total of 2,028 visits to the pediatric emergency room (ER) in a teaching institution made by children enrolled in the institution's primary care clinic were analyzed to determine how residents assigned follow-up (FU) visits. Of the ER visits, 841 (41.5%) resulted in an FU appointment. Problems such as acute asthma, pneumonia, and otitis media, for which FU is usually advised by pediatric textbooks and by the faculty of our institution, did not automatically result in appointments for FU. Those illnesses for which FU may not have been indicated were appointed. Focused teaching about the FU management of problems for which care is provided in an ER is needed.
Appointments and Schedules↗
The resolution of health problems in school children.
The resolution rates of health problems identified in school children by primary care, physical examination, or screenings were examined during a two-year period. The evaluation component of the National School Health Program involved a range of school health services provided in four states to more than 13,000 children. A school nurse practitioner-health aide team worked in collaboration with a community physician consultant to manage the resolution of identified problems. More than 95% of the problems were resolved or in process of resolution at the end of each school year. Resolution patterns were relatively consistent across problem severity levels. Factors contributing to the timely resolutions of health problems by nurse practitioners included their ability to manage and resolve more than 90% of the problems within the school-based practice with physician backup and their access to a medical support network for external referrals.
Child↗
Serum immunoglobulins in the first year of life.
Serum IgG, IgM, and IgA were measured in 316 infants younger than 12 months of age. Information including the child's race, sex, age, and past history of infections or atopy was collected. Birth records were also reviewed to ascertain the child's birthweight and gestational age. Serum IgG levels were higher in black infants than in white infants after the age of 4 months. Serum IgM levels were higher in black females than in black males for infants older than 1 month. For infants younger than 4 months of age, those weighing less than 2500 g at birth had lower IgG levels than those weighing more than 2500 g. Infants younger than 1 month whose gestational age had been less than 36 weeks had lower IgG levels than those greater than 36 weeks. Infants aged 1 to 4 months whose gestational age had been less than 36 weeks had lower IgG levels than did those 40 or more weeks. Infants with a positive history for atopy had lower IgG levels than similarly aged infants with a negative history.
Age Factors↗
Use of the emergency department by children enrolled in a primary care clinic.
Two thousand forty-four emergency department (ED) visits were made during a one-year period by 714 children enrolled in a primary care clinic. Eight hundred one (39.2%) visits were for urgent or emergent conditions, and 579 (28.3%) were for presenting complaints suggestive of urgent or emergent conditions, including 65 based on parental concern. Six hundred sixty-four (32.5%) visits might have been considered medically inappropriate using criteria specifically developed for this study. These criteria were developed as a standard which might be used for future studies on ED use by children. Children without medical assistance and those over 12 months of age were more likely to be consistently appropriate users. Appropriateness of use was not associated with the patient's race, sex, distance of home from the hospital, telephone availability, length of clinic enrollment, type of primary provider, or chronic disease other than asthma. Further, medical assistance recipients were more likely to make three or more inappropriate visits than were the other groups.
Emergency Service, Hospital↗
Role for dual individualization with cefmenoxime.
Cefmenoxime concentration/effect relationships were retrospectively explored for gram-negative bacteria isolated from 14 critical care patients treated for nosocomial pneumonia. The effects of cefmenoxime concentrations on in vitro growth kinetics of 21 isolated pathogens were studied using the Abbott MS-2 Research System, from which a dynamic response concentration was derived. Serum pharmacokinetic profiles were obtained in each patient. These data were used to calculate the in vivo total area under the curve over dynamic response concentration and the time that cefmenoxime concentrations exceeded the dynamic response concentration for each bacteria. The same determinations were made in 18 patients prospectively treated, except that dosage was optimized on the basis of previous mathematical relations to achieve bacterial eradication in four days. This method of dosage optimization is termed dual individualization. Serial cultures of infected tissues were evaluated to determine the number of days to the eradication of bacteria, and the pharmacokinetic and pharmacodynamic variables were used to describe the bacteriologic response of the original pathogen isolated in pretreatment culture. Bacterial eradication rates could be described from cefmenoxime pharmacokinetics in the patient and from the relation between concentration and bacterial inhibition. Patients who were prospectively treated using these retrospectively derived relationships had a predictable day of bacterial eradication. This, in turn, was associated with a shorter duration of treatment (p less than 0.05). The success of prospective dual individualization is encouraging and suggests that more precise optimization of antibiotic dosage can yield a predictable rate of bacterial eradication from the infection site.
Aged↗
Iatrogenic risks and financial costs of hospitalizing febrile infants.
We identified, by diagnostic categories, the iatrogenic and financial costs that arise from hospitalizing febrile infants 60 days of age or younger. Thirty-seven (19.5%) of all admissions resulted in 48 separate complications. Twenty-nine (60.4%) of these complications were preventable, and six complications (12.5%) occurred in infants who probably did not require hospitalization for therapy. Twenty-four (50%) of all complications resulted from intravenous therapy. In addition to the complications, 26 diagnostic misadventures were identified. The average length of hospitalization for all infants was 7.0 days, with a range of two to 28 days. The average cost of hospitalization in 1979-80 dollars was $2,130 per infant, with a range from $6,345 for those infants with bacterial meningitis to $1,480 for those infants with aseptic meningitis. On the average, 25.6% of the bill was for diagnostic studies and 8.3% for physician fees.
Anti-Bacterial Agents↗
Hospitalization v outpatient treatment of young, febrile infants.
Our medical center has an unwritten policy of admitting all febrile infants younger than 2 months of age. We studied this practice during a three-year period to determine what proportion of the febrile infants who came to the outpatient department were admitted. The characteristics of the infants who were not admitted were compared with those who were. The timing of and the infant's status at a subsequent visit for those not admitted were also identified. One hundred six (35%) of 303 encounters with young, febrile infants did not result in admissions. An infant was more likely to be admitted if he was male, younger than 30 days of age, and febrile (greater than 38.5 degrees C). None of the infants who were followed up as outpatients suffered morbidity that could be directly related to their not having been hospitalized.
Age Factors↗
Which children with febrile seizures need lumbar puncture? A decision analysis approach.
Whether all children brought to the emergency room with a first seizure and fever require lumbar puncture (LP) remains controversial. We reviewed the emergency room records of 241 children aged 6 months to 6 years who had this clinical picture. Five history and physical examination items discriminated between children with and without meningitis: a physician visit within 48 hours before the seizure; the occurrence of convulsions on arrival at the emergency room; a focal seizure; suspicious findings on physical and/or neurologic examination. Used in combination, these items (risk factors) identified all children with meningitis but would have spared 62% of children without meningitis the need for LP. In a decision analysis framework, they were as sensitive but more specific than LP in detecting children with meningitis. Most important, their negative predictive value was 100%.
Child↗