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Biomedical subjects

K N Shaw

Publications and source records attributed to K N Shaw.

At least 37 records · Page 2Linked to original sources
PubMed1997

Evaluation of a rapid screening filter test for urinary tract infection in children.

OBJECTIVE: Clinical evaluation of a rapid screening filter test for urinary tract infection (UTI), FiltraCheck-UTI, comparison to the urine dipstick and conventional urinalysis for test performance and cost effectiveness in children. SETTING: Pediatric emergency department at an urban children's hospital. METHODS: Cross-sectional concordance study of 1298 children age 2 days to 19 years (50% < or = 2 years) for whom a urine culture was ordered; screening tests run by trained laboratory personnel; cost per case detected calculated; retrospective chart review for clinical information. RESULTS: Prevalence of UTI was 7.1%. Urine obtained from children < or = 2 years by catheter (97%) as part of an evaluation of fever or sepsis (82%). FiltraCheck-UTI was comparable with microscopy for bacteriuria (P = 0.11), sensitivity of 85% (95% confidence interval, 76 to 91) and specificity of 72% (95% confidence interval, 70 to 75%) but it was difficult detect Gram-positive organisms by this method (P < 0.001). Its performance varied by definition of UTI. The urine dipstick had the best specificity and was the most cost-effective rapid test. CONCLUSIONS: FiltraCheck-UTI is more expensive and has more false positives than the urine dipstick in detecting UTI in children. The dipstick continues to be the best inexpensive alternative to microscopy, but it is probably not an adequate screen for when to send a urine culture in young children.

Adolescent↗
PubMed1997

Effect of fever on capillary refill time.

OBJECTIVE: To assess the effect of fever on capillary refill time in children. DESIGN: Prospective cohort study. SETTING: Tertiary care children's hospital emergency department (ED). PARTICIPANTS: Convenience sample of 234 children age one month to five years presenting to the ED with a complaint of vomiting, diarrhea, or poor oral fluid intake. INTERVENTION: None. MEASUREMENTS: Before any therapy, capillary refill was measured according to a standard protocol. Rectal temperature was measured in children less than three years old, oral temperature in older children. Fluid deficit was calculated as the percentage difference between initial weight and stable weight following treatment. MAIN RESULTS: Among the 80 children with dehydration, defined as a deficit of > or = 5% of body weight, mean capillary refill was 2.0 +/- 1.0 seconds, versus 1.3 +/- 0.5 seconds in the well hydrated group (P < 0.001). Within each group, mean capillary refill time for febrile patients (temperature > or = 38.3 degrees C) was essentially the same as in those without fever. Using a two-second upper limit of normal, prolonged capillary refill had a sensitivity of 0.44 and specificity of 0.94 for diagnosing dehydration; the diagnostic performance did not differ when stratified by presence or absence of fever. CONCLUSIONS: Presence of fever does not have a clinically important effect on capillary refill time in children.

Capillaries↗
PubMed1997

The effect of insurance status on likelihood of neonatal interhospital transfer.

OBJECTIVE: To determine the effect of insurance status on the likelihood of interhospital transfer for neonates. DESIGN: Population-based retrospective cohort study. SETTING: All general acute care nonpediatric hospitals in the five counties of southeastern Pennsylvania. PATIENTS: Fifty-six thousand, seven hundred eighty-nine infants from 0 to 28 days of age admitted to or born in study hospitals between January 1 and December 31, 1991. INTERVENTION: None. MAINS OUTCOME MEASURE: Transfer to another general or specialty acute care hospital. RESULTS: The incidence (95% confidence interval) of interhospital transfer was 1.69% (1.60, 1.78). Uninsured infants were nearly twice as likely [relative risk (RR) = 1.96 (1.67, 2.31)] to be transferred as commercially insured infants, even when adjusted for the effects of prematurity, severity of illness, and the level of neonatal intensive care unit in the referring hospital. Similarly, infants with Medicaid were more likely to be transferred [RR = 1.20 (1.01, 1.43)] than similar commercially insured neonates. Uninsured and publicly insured infants were also more likely to be born premature [RR 1.49 (1.39, 1. 60)] than privately insured neonates, and were more likely to have both moderate [RR 1.11 (1.04, 1.23)] and high [RR 1.21 (1.11, 1.32)] illness severity on admission to the hospital than privately insured infants. CONCLUSIONS: Neonates with no insurance and those with Medicaid coverage were more likely to be transferred than infants with private insurance. These results are consistent with those of other investigators who have studied financially motivated patient transfers- so-called patient dumping-in nonpediatric populations of patients. Our study may represent the first documentation of this phenomenon in a pediatric population. Our results are also consistent with those of other investigators who have examined the effect of insurance status on maternal interhospital transfer, thus providing further evidence for the existence of financially motivated transfers within regional systems of perinatal care. Future investigation into the effect of economic factors on variation in the utilization of transport services, and on how transfer influences ultimate patient outcome, is needed as managed care health systems become more widespread.

Analysis of Variance↗
PubMed1997

Validity and reliability of clinical signs in the diagnosis of dehydration in children.

OBJECTIVE: To determine the validity and reliability of various clinical findings in the diagnosis of dehydration in children. DESIGN: Prospective cohort study. SETTING: An urban pediatric hospital emergency department. PARTICIPANTS: One hundred eighty-six children ranging in age from 1 month to 5 years old with diarrhea, vomiting, or poor oral fluid intake, either admitted or followed as outpatients. Exclusion criteria included malnutrition, recent prior therapy at another facility, symptoms for longer than 5 days' duration, and hyponatremia or hypernatremia. METHODS: All children were evaluated for 10 clinical signs before treatment. The diagnostic standard for dehydration was fluid deficit as determined from serial weight gain after treatment. MAIN RESULTS: Sixty-three children (34%) had dehydration, defined as a deficit of 5% or more of body weight. At this deficit, clinical signs were already apparent (median = 5). Individual findings had generally low sensitivity and high specificity, although parent report of decreased urine output was sensitive but not specific. The presence of any three or more signs had a sensitivity of 87% and specificity of 82% for detecting a deficit of 5% or more. A subset of four factors-capillary refill >2 seconds, absent tears, dry mucous membranes, and ill general appearance-predicted dehydration as well as the entire set, with the presence of any two or more of these signs indicating a deficit of at least 5%. Interobserver reliability was good to excellent for all but one of the findings studied (quality of respirations). CONCLUSIONS: Conventionally used clinical signs of dehydration are valid and reliable; however, individual findings lack sensitivity. Diagnosis of clinically important dehydration should be based on the presence of at least three clinical findings.

Bayes Theorem↗
PubMed1997

Pediatric Emergency Medicine (PEM) fellowship: essentials of a three-year academic curriculum. Three-Year Academic Subcommittee of the PEM Fellowship Committee of the Section of Emergency Medicine, American Academy of Pediatrics.

This committee of fellowship directors has proposed guidelines for an academic curriculum for training fellows in PEM. The curriculum should be modified to each unique program, but is based on current expectation of the American Board of Pediatrics and the ACGME for graduate education. This is the first PEM academic curriculum document in publication. Ongoing refinement and adaptation based on feedback from fellows and directors is essential to provide the best fellowship experience to our trainees. The proposed curriculum is also subject to further change as more details are given for ACGME approval of the fellowship programs.

Curriculum↗
PubMed1995

Ten-year review of pediatric bathtub near-drownings: evaluation for child abuse and neglect.

STUDY OBJECTIVE: To evaluate the risk factors associated with bathtub submersion injury and their relationship to child abuse and neglect. DESIGN: Retrospective chart review. SETTING: An urban children's hospital. PARTICIPANTS: Any child sustaining a bathtub near-drowning over the 10-year period from 1982 to 1992. INTERVENTIONS: None. RESULTS: Twenty-one patients were treated for bathtub near-drownings during the 10-year period, accounting for 24% of all submersion injuries. A significant number (67%) had historic and/or physical findings suspicious for abuse or neglect, including incompatible history for the injury, other physical injuries, previous child abuse reports, psychiatric history of the caretaker, and/or psychosocial concerns noted in the chart. The mortality rate of 42% was significant. No demographic characteristics identified the children at risk. CONCLUSION: Many children who are injured in the bathtub suffer from abuse or neglect. Medical evaluation should include social work consultation and a search for other accompanying injuries.

Child↗
PubMed1994

Violence in the pediatric emergency department.

STUDY OBJECTIVE: To identify the frequency of violence and the perception of safety in pediatric emergency departments. STUDY DESIGN: Descriptive, cross-sectional survey of directors of pediatric EDs with fellowship programs. SETTING: University-based urban pediatric EDs. PARTICIPANTS: Forty-seven pediatric ED directors were surveyed, with 94% responding. RESULTS: More than three-fourths of those responding reported one or more verbal threats per week; 77% reported one or more physical attacks on staff per year; and 25% reported actual injury to staff. No pediatric EDs had weapon detectors; 7% had city police stationed there; and 54% had 24-hour security stationed in the pediatric ED. The majority reported that their staff members practice with at least occasional fear (55%) and had documented this concern (82%). Perception of safety was associated with the incidence of verbal threats (P < .006), physical attacks (P < .03), injury to staff or patient (P < .01), and the frequency with which security was needed (P < .001). Pediatric EDs with 50,000 or more visits per year were more likely to have multiple physical attacks on staff (relative risk, 2.89; 95% confidence interval, 1.33-6.26; P < .004). More verbal threats were reported in pediatric EDs with longer waiting times (P < .001). Fewer than half of the pediatric EDs with reported injuries had 24-hour security. CONCLUSION: Pediatric EDs are not immune to the problem of violence. Efforts must be directed to increase safety through better security, more efficient patient care, and aggression management training.

Attitude of Health Personnel↗
PubMed1993

Effect of ambient temperature on capillary refill in healthy children.

OBJECTIVES: To assess the effect of moderately decreased ambient temperature on capillary refill (CR) time in healthy children, and to measure the reliability of CR measurements between observers. DESIGN: Prospective interventional study with cross-over design. SETTING: Urban pediatric emergency department. PARTICIPANTS: 32 well-hydrated children aged 1 month to 12 years brought to the emergency department for care of minor illness or injury. INTERVENTIONS: Participants were assigned in random order to a 15-minute waiting period in each of two rooms, with and without air-conditioning (cool and warm rooms, respectively). At the end of each waiting period, fingertip CR was measured with a stopwatch, three times by each of one or more three trained observers. RESULTS: Mean CR time was 0.85 +/- 0.45 seconds in the warm room (mean ambient temperature (25.7 degrees C) vs 2.39 +/- 0.76 seconds in the cool room (mean temperature 19.4 degrees C). The mean overall difference in CR time between the two environments was 1.53 seconds (95% confidence interval [CI]: 1.31, 1.75; P < .001); the difference was significant regardless of age or sequence of exposure. 100% of patients were considered to have normal CR (less than 2 seconds) in the warm room, whereas only 31% were considered normal in the cool room. In the 16 patients with CR measured by three observers, interobserver reliability was fair, with an intraclass correlation coefficient of 0.70 (95% CI: 0.56, 0.85), and kappa of 0.54 (95% CI: 0.33, 0.73). CONCLUSIONS: Decreases in ambient temperature within a range found in typical office/emergency department settings may cause significant prolongation of CR time in children with normal circulatory status. There is marked interobserver variability in the measurement of CR even when performed by experienced observers. These findings suggest limitations to the use of CR in the assessment of ill or injured children.

Body Temperature↗
PubMed1993

Near drowning: is emergency department cardiopulmonary resuscitation or intensive care unit cerebral resuscitation indicated?

OBJECTIVES: a) To report the neurologic outcome of a series of near-drowning victims treated with supportive management without aggressive cerebral resuscitation; and b) to identify patient characteristics that indicate prognosis and guide therapy at the scene, the Emergency Department, and in the intensive care unit (ICU). DESIGN: Retrospective review of all near-drowning patients requiring admission to the ICU over a 6-yr period (1/1/82 to 12/31/88). Hospital records were examined for the circumstances of submersion and rescue, patient condition on arrival in the Emergency Department and ICU, treatments, hospital course, and ultimate outcome. SETTING: Emergency departments of the referring hospital and ICU of Children's Hospital. PATIENTS: Forty-four pediatric submersion victims were treated with therapy limited to the support of vital functions. Three patients who met cold-water drowning criteria were excluded from the analysis for predictors of neurologic outcome. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: In our warm-water near-drowning patients, 56% survived neurologically intact, 32% survived in a persistent vegetative state, and the remaining 32% died. Unreactive pupils in the Emergency Department and a Glasgow Coma Score of < or = 5 on arrival to the ICU were the best independent predictors of poor neurologic outcome (odds ratio and 95% confidence intervals 374 [17 to 16,000] and 51 [5 to 2,200], respectively). However, no predictor was absolute and two nonhypothermic patients who arrived to the Emergency Department without vital signs, requiring cardiopulmonary resuscitation and cardiotonic medications, had full neurologic recovery. CONCLUSIONS: Our results cast further doubt on the utility of aggressive forms of cerebral monitoring and resuscitation and emphasize the need for initial full resuscitation in the Emergency Department.

Adolescent↗
PubMed1991

Outpatient assessment of infants with bronchiolitis.

Two hundred thirteen infants younger than 13 months with bronchiolitis were prospectively followed up to identify the historical, physical, and laboratory clues at initial emergency department evaluation that would help to predict disease severity. Based on their total course of illness, the patients were classified as having mild (139 patients) or severe (74 patients) disease, and the initial emergency department evaluation findings of these two groups were compared. Six independent clinical and laboratory findings were identified that were strongly associated with more severe illness: (1) "ill" or "toxic" general appearance; (2) oxygen saturation less than 95%, as determined by pulse oximetry; (3) gestational age, younger than 34 weeks; (4) respiratory rate, 70/min or greater; (5) atelectasis on a chest roentgenogram; and (6) age, younger than 3 months. The infant's oxygen saturation as determined by pulse oximetry was the single best objective predictor of more severe disease.

Age Factors↗
PubMed1990

Indigent children who are denied care in the emergency department.

We conducted a six-month prospective study of the diagnoses and outcomes of 588 children who were denied care in our emergency department under a new primary-care case management health system for 100,000 indigent patients. The mean patient age was 4.7 years (39% were less than 2 years old). The most common presenting complaints were colds, earaches, rash, vomiting, and diarrhea. Nine percent of children presented for trauma, and 10% had fever of more than 38.2 C. Follow-up was available from the primary care physician for 388 children (66%). Of the 60% of patients who kept their arranged appointment, 42% received antibiotics, 3% were referred for further evaluation, and two children were hospitalized. Follow-up was available from the parents for 125 children (21%). No follow-up information of any kind was available for 111 children (19%), and no follow-up regarding the health of the child was available for 265 children (45%). This last group included 10% with a chief complaint of trauma and 6% with temperature of more than 39 C. Forty-nine percent of patients in this group were less than 2 years old.

Appointments and Schedules↗
PubMed1989

Submersion injuries: drowning and near-drowning.

Submersion injuries are a major cause of morbidity and mortality in children and young adults. The Emergency Department physician should be familiar with the epidemiology, pathophysiology, modes of therapy, and prognostic indicators in order to provide optimum resuscitation to the near-drowning victim, correct referral, and counseling to their families.

Emergencies↗