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The purpose of this study was to compare the Jackson-Rees circuit with the pediatric circle and MERA F breathing system (MERA F system) for pediatric anesthesia from the viewpoint of work of breathing (WOB). Twenty-three children (2-10 yr old) were studied during spontaneous breathing under endotracheal anesthesia with 4 L/min nitrous oxide, 2 L/min oxygen, and 1% end-tidal concentration of sevoflurane. WOB, inspiratory and expiratory airway resistance, dynamic compliance (CDYN), pressure time product (PTP), and arterial blood gasses were measured in the three circuits. The inspiratory WOB was estimated directly by measuring the esophageal pressure-volume loop using the Campbell technique. In a laboratory study, we measured the compliances of the Jackson-Rees circuit, the pediatric circle, the MERA F system, and the adult circuit. WOB differed among the three circuits (MERA F system > pediatric circle > Jackson-Rees circuit). Inspiratory and expiratory resistances, and arterial carbon dioxide tension in the Jackson-Rees circuit were significantly lower than those of both the pediatric circle and MERA F system. The CDYN and PTP in the MERA F system were significantly higher than those in both the Jackson-Rees circuit and the pediatric circle. The MERA F system had significantly higher compliance than the Jackson-Rees circuit and pediatric circle. It is concluded that the Jackson-Rees circuit is most efficient, the pediatric circle is intermediate, and the MERA F system is the least efficient from the viewpoint of WOB during spontaneous breathing for pediatric anesthesia.
OBJECTIVES: Observation units (OUs) are widely used to care for adults, but little is published about their use in pediatrics. During the planning stages of our pediatric OU, community primary medical doctors (PMDs) expressed concerns about not admitting and managing their own patients in this unit controlled by pediatric emergency physicians. This study surveyed PMDs to determine their satisfaction with the pediatric OU two and a half years after opening. METHODS: A satisfaction survey was mailed to pediatricians, family practitioners, and pediatric subspecialists whose patients had been admitted to the study pediatric OU from August 1999 to January 2002. A Likert scale ranging 1 to 4 was used to measure satisfaction in 4 areas. In addition, there were questions regarding the utility of the OU for treatment of common pediatric illnesses. RESULTS: 198 of 248 (80%) surveys were returned. Pediatricians (64%) and family practitioners (23%) were represented most often. Fifty-three percent of PMD respondents had 10 or more patients admitted during the study period. Median satisfaction scores were 4 (most satisfied) in all areas measured. Over 60% of physicians surveyed felt that the OU was useful in the treatment of dehydration, gastroenteritis, reactive airway disease, and bronchiolitis. CONCLUSIONS: The model of an ED-controlled pediatric observation unit received high satisfaction ratings in all areas by community and subspecialty physicians two and a half years after opening. The initial reservations voiced by community physicians have not resurfaced.
OBJECTIVES: To estimate (1) the average number of patients per practitioner in Pediatric Research in Office Settings, the national practice-based research network of the American Academy of Pediatrics; (2) the total number of active patients cared for in the network; and (3) the age-sex distribution of patients seen in pediatric practice. SETTING: Eighty-nine practices in 31 states with 373 Pediatric Research in Office Settings practitioners (59% of Pediatric Research in Office Settings members). METHODS: Practices were asked to enumerate the number of patients visiting the practice during the 2-year period from January 1, 1991, through December 31, 1992. Patients making multiple visits were counted only once, resulting in a patient count rather than a visit count. Age-sex registers were completed using computer billing records or medical record sampling. RESULTS: Study participants cared for 529513 active patients (50.7% male). Each practitioner cared for an average of 1546 patients. The number of patients per practitioner was significantly higher in less-populated areas and in solo practices. Children aged 12 years and younger comprised 81% of the patients seen by Pediatric Research in Office Settings practitioners, and more than half of the children were aged 6 years or younger. Before age 5 years, boys accounted for a slightly, but significantly, higher number of patients, whereas after age 14 years, girls comprised a significantly larger proportion of patients. CONCLUSIONS: The average number of 1546 patients per practitioner derived from these private practice data is in line with health maintenance organization-based estimates. Pediatric practitioners predominantly serve younger children. These data provide the only current national estimates of the size and age-sex distribution of independent pediatric practices, and can help pediatricians and health service researchers plan for the future provision of health care to children.
CONTEXT: Approximately 50% to 75% of drugs used in pediatric medicine have not been studied adequately to provide appropriate labeling information. In 1997, Congress passed the Food and Drug Administration Modernization Act (FDAMA), which encouraged pediatric drug development by providing an incentive in the form of additional marketing exclusivity. OBJECTIVE: To identify new drug labeling information from pediatric studies submitted to the FDA in response to written requests. DESIGN AND SETTING: Between July 1998 and April 1, 2002, the FDA requested studies on 242 drugs, and 53 drugs were granted exclusivity. As of January 2003, 49 drugs have new labels. Data from the studies of the first 33 drugs with new pediatric information on the label as of April 2002 are included. Significant labeling information was analyzed along with baseline data and types of studies requested. MAIN OUTCOME MEASURES: Safety data and pediatric information for labeled drugs. RESULTS: There were 53 studies for 33 drug products, 12 (23%) were evaluated for safety only; 23 (43%), safety and efficacy; and 18 (34%), pharmacokinetics and/or pharmacodynamics. Significant new dosing and/or safety information was identified for 12 (36%) drugs. New dosing information was determined for 7 of these drugs. Safety information was defined for gabapentin, propofol, sevoflurane, the combination of ribavirin and interferon alfa-2b, and various betamethasone-containing dermatologic preparations. There was a higher percentage of deaths reported with patients who received propofol compared with controls in the pediatric intensive care unit. Seizures were seen in patients administered sevoflurane. Patients receiving a combination of ribavirin and interferon alfa-2b experienced an increased incidence of suicidal ideation when compared with adults. An unexpectedly high percentage of those receiving betamethasone-containing dermatologic preparations had documented hypopituitary-adrenal axis suppression. CONCLUSION: The FDAMA has stimulated pediatric clinical studies resulting in improved understanding of the pharmacokinetics of drugs prescribed in pediatric medicine, important dose changes, and improved safety for children taking certain drugs.
BACKGROUND: The Internet has revolutionized access to biomedical information among health professionals and the general public. There is demand for pediatric societies to develop quality contents directed at both pediatricians and parents. OBJECTIVE: To evaluate interaction through the Internet among parents and the pediatric societies in Spain and member organizations of the Latin American Pediatric Association. MATERIAL AND METHODS: All the official Spanish pediatric societies (n = 45) and the national organizations belonging to the Latin American Pediatric Association (25) were examined. Societies with their own websites (26 in Spain and 13 in Latin America) were identified. For each website, the following data were collected: size, access to contents, adherence to an ethical code, terms of use, division of contents for pediatricians and those for parents, and means of contact for parents. RESULTS: All the websites provided free access to biomedical information. Only 35 % of websites from Spain and 15.4 % of those from the Latin American Pediatric Association subscribed to an ethical code while 54 % and 84.6 % respectively had no terms of use section. Overall, 46 % had a specific area for parents. The most common means of contact between parents and websites was through electronic mail and 5 % of the sites explicitly accepted online consultations. Only six out of 39 websites fulfilled all the criteria evaluated. CONCLUSIONS: The presence of pediatric societies on the Internet is acceptable, without noteworthy differences between Spanish organizations and member organizations of the Latin American Pediatric Association. In general, interaction with parents is of poor quality.
OBJECTIVE: To study the impact of a clinical pharmacist in a pediatric intensive care unit. The goals of the study were to determine the type and quantity of patient care interventions recommended by a clinical pharmacist and to specifically examine cost savings (or loss) that resulted from clinical pharmacist recommendations. DESIGN: A prospective case series. SETTING: Ten-bed pediatric intensive care unit in a university-affiliated children's hospital. PATIENTS: All patients admitted to the pediatric intensive care unit during the study period. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: During the 24-wk study period, the pediatric clinical pharmacist documented all interventions that occurred during her shift. She rounded with the pediatric intensive care unit team approximately two times a week and reviewed medication lists daily. Drug acquisition costs were used to calculate drug cost savings. Demographic information was collected on all the patients in the pediatric intensive care unit during the study period. There were 35 recommendations per 100 patient days. The most common interventions were dosage changes (28%), drug information (26%), and miscellaneous information (22%). The average time spent per day by the clinical pharmacist in the pediatric intensive care unit was 0.73 hrs or 0.02 full-time equivalent. The total cost direct savings for the study period was $1,977. Extrapolated to direct cost savings per year, the total amount saved was $9,135/year or 0.15 full-time equivalent. Indirect savings from educational activities, avoidance of medication errors, and optimization of medical therapies represent an additional nonquantifiable amount. CONCLUSION: We conclude that a clinical pharmacist is an important and cost-effective member of the pediatric intensive care unit team.
OBJECTIVE: To summarize the demographics and practice patterns of the current pediatric critical care workforce and to identify the key workforce issues that may affect the delivery of pediatric critical care services in the future. DESIGN: A questionnaire designed to analyze current pediatric critical care workforce demographics and future workforce trends. SUBJECTS: Pediatric critical care physicians from the United States were identified from the American Academy of Pediatrics Critical Care Section, from a list of physicians certified in pediatric critical care medicine (PCCM) by the American Board of Pediatrics, and from a list of pediatrician members of the Society for Critical Care Medicine. INTERVENTIONS: None. MEASUREMENTS: PCCM physicians were polled regarding board certification, practice characteristics, professional activities, referral patterns, patient profiles, competition, job satisfaction, and projected retirement age. MAIN RESULTS: A total of 805 PCCM physicians completed the survey. When grouped by age, 40% of the responding PCCM physicians were younger than 40 yrs, 49% were 40 to 49 yrs old, and only 11% were 50 yrs of age or older. The younger group had a higher percentage of female pediatricians than the older groups. For all age groups, the largest proportion of time was devoted to direct patient care time in pediatric critical care. This was especially true for the youngest age group that had the largest amount of patient care time devoted to critical care (43%). Time devoted to research was also significantly higher for the younger age group, although very few respondents reported that they have >50% of their time protected for research. For all age groups, those reporting increases in referral volume and referral complexity over the previous 12 months far outnumbered those reporting decreases. The majority of respondents reported being satisfied with their career choice. In general, respondents were more likely to report that too many rather than too few PCCM physicians were currently being trained. Approximately one third of respondents (34%) planned on leaving the field of critical care medicine before retiring from medicine completely. CONCLUSIONS: PCCM physicians were increasingly women and working for >65 hrs/wk, with a good level of job satisfaction. Competition from a variety of sources seems to affect the work of PCCM physicians. The relatively small percentage of time devoted to research, however, is a finding of great concern.
To summarize the quantity, quality, and subject matter of articles pertaining to pediatric dermatology in current pediatric and dermatologic journals, 2,010 articles published in 1981 in 9 clinical journals were reviewed. Of articles in the pediatric journals, 4% had a primary dermatologic focus, and another 6% had a secondary dermatologic focus. Of the clinical articles in the dermatologic journals, 15% concerned only pediatric patients, and an additional 18% involved both pediatric and adult patients. The great majority of pediatric (65%) and dermatologic (83%) articles concerning pediatric dermatology were case reports, with lesser proportions of research reports and review articles. There was a relative scarcity of prospective clinical studies describing either the natural course of pediatric skin diseases or the effects of various therapies upon these diseases. Frequent topics of articles in both types of specialty journals included cutaneous manifestations of systemic disease, hereditary skin disorders, and bacterial skin infections. It is hoped that interest in this important field will promote mutually beneficial collaboration between pediatricians and dermatologists in the areas of patient care and clinical research.
BACKGROUND: Exanthems in children often represent a diagnostic challenge. PURPOSE: To determine the concordance between pediatric and dermatological diagnoses of exanthems. DESIGN: Prospective study. PROCEDURE: Exanthems that appeared in hospitalized pediatric patients were diagnosed by pediatricians. Pediatric dermatologists, by consensus, either confirmed or modified the diagnoses. Whenever possible, laboratory tests were used to confirm the final clinical diagnoses. Age and evolution were compared with the Kruskal-Wallis test; the kappa coefficient was used to determine concordance. SETTING: Institutional tertiary referral pediatric care center. RESULTS: Concordance between pediatric and dermatological diagnoses was found in only 44 patients. When pediatric and dermatological diagnoses of exanthems were classified, the concordance between both diagnoses was very low (kappa = 0.165). CONCLUSIONS: Pediatric specialists, other than dermatologists, failed to diagnose common skin diseases. This may be a consequence of insufficient training in dermatology by medical schools and pediatric residency.
BACKGROUND: Competence in basic orthopedic assessment and interpretation of radiographs is important for pediatricians because appropriate initial management of fractures can expedite therapy and minimize morbidity. However, requirements for training in orthopedics and radiology are poorly defined in pediatric residency programs. OBJECTIVE: To assess the ability of pediatric residents to recognize and to manage appropriately pediatric fractures. METHODS: This study involved administration of a case-based questionnaire with radiographs to volunteer categorical pediatric residents in 3 geographically diverse training programs. The diagnosis and management of 8 orthopedic complaints were evaluated. Responses were scored according to the number of features identified accurately, including the presence or absence of a fracture. Residents who were able to identify a fracture were assessed with respect to their ability to classify the fracture and to provide initial management. The study was pretested with a group of pediatric emergency medicine attending physicians, to establish the suitability of the cases. RESULTS: Among the 3 residency sites, 102 of 190 eligible pediatric residents (53.7%) participated, yielding 95 completed questionnaires. The mean number of cases in which a resident correctly answered the question, "Is a fracture present?" and correctly identified the fractured bone (if a fracture was present) was 6.5 +/- 1.2 of 8 cases (81.6%; 95% confidence interval: 78.5-84.7%). The diagnostic accuracy of Salter-Harris classification in cases in which such fractures were present was 40.9%. The mean score of correctly identified features for the resident group was 38.5 +/- 9.4, of a possible 64 points (proportion correct: 60.1%; 95% confidence interval: 57.2-63%). There was a small but significant difference in mean correct responses between first-year residents (proportion correct: 55.4%; 95% confidence interval: 50.8- 60.3%) and third-year residents (proportion correct: 65.1%; 95% confidence interval: 60.7-69.5%). There was no association between the proportion of correct responses and whether or not residents had taken radiology or orthopedics elective courses in medical school. Overall, 43% of cases were both identified and managed correctly by the pediatric residents. CONCLUSIONS: For residents from the participating training programs, skills in recognizing and managing pediatric fractures were suboptimal. Additional review of training requirements is necessary to identify more clearly areas of improvement for current curricula.
A national Task Force on Developmental Pediatrics was convened in 1979 to produce a curriculum for pediatric residents pertaining to the detection, assessment, and management of children with atypical development. During a 2-year period, the task force developed a structured curriculum composed of specific goals, educational objectives, and matched learning activities that identified and described the basic knowledge, skills, and attitudes of developmental pediatrics to be acquired during a pediatric residency. Subsequently, the curriculum was implemented and evaluated in 11 pediatric programs with a developmental pediatrics rotation. On a seven-point subjective scale, the mean resident (n = 64) rating of the curriculum's usefulness was 6.0 and of their perceived competence in the skills of developmental pediatrics was 5.2; the mean percent of this competence attributed to the curriculum-based rotation was 56.6. On an objective case management test, residents who used the curriculum scored significantly (P less than .005) higher than those who did not. These results suggest the efficacy of structured curricula in pediatric resident education.
From the first meeting of the Japanese Society of Pediatric Surgeons in 1964 a small group discussion on anesthetic problems and patient care was held by some anesthesiologists at night. The Association of Pediatric Anesthesiologists (started in 1971) has undertaken the night meeting ever since the twelfth Annual Meeting of the Society of Pediatric Surgeons in 1975. The problems about pediatric respiratory management, neonatal emergency surgery and pediatric anesthesia were discussed frequently by doctors in different specialties. The recent decrease of mortality in neonatal surgery is thought to have come from the improvement of pediatric respiratory management. This night meeting of anesthesiologists has had a major role in the resolution of problems in pediatric respiratory impairment. The problems to be resolved in an emergency--persistent fetal circulation, barotrauma, nutritional problems in long term ventilatory support and so on--, will be discussed in the future. The purpose of this association is to elevate the quality of pediatric anesthesiologists by discussion with the other specialists of medicine and to make clear their responsibility in Children's Hospitals or Centers.
OBJECTIVES: This study was designed to compare outcome after adult defibrillation dosing versus pediatric dosing in a piglet model of prolonged prehospital ventricular fibrillation (VF). BACKGROUND: Weight-based 2 to 4 J/kg monophasic defibrillation dosing is recommended for children in VF, but impractical for automated external defibrillator (AED) use. Present AEDs can only provide adult shock doses or newly developed attenuated adult doses intended for children. A single escalating energy sequence (50/75/86 J) of attenuated adult-dose biphasic shocks (pediatric dosing) is at least as effective as escalating monophasic weight-based dosing for prolonged VF in piglets, but this approach has not been compared to standard adult biphasic dosing. METHODS: Following 7 min of untreated VF, piglets weighing 13 to 26 kg (19 +/- 1 kg) received either biphasic 50/75/86 J (pediatric dose) or biphasic 200/300/360 J (adult dose) therapies during simulated prehospital life support. RESULTS: Return of spontaneous circulation was attained in 15 of 16 pediatric-dose piglets and 14 of 16 adult-dose piglets. Four hours postresuscitation, pediatric dosing resulted in fewer elevations of cardiac troponin T (0 of 12 piglets vs. 6 of 11 piglets, p = 0.005) and less depression of left ventricular ejection fraction (p < 0.05). Most importantly, more piglets survived to 24 h with good neurologic scores after pediatric shocks than adult shocks (13 of 16 piglets vs. 4 of 16 piglets, p = 0.004). CONCLUSIONS: In this model, pediatric shocks resulted in superior outcome compared with adult shocks. These data suggest that adult defibrillation dosing may be harmful to pediatric patients with VF and support the use of attenuating electrodes with adult biphasic AEDs to defibrillate children.
Autopsy rates and clinicopathologic correlations for pediatric autopsies and the subgroup of pediatric oncology autopsies in a large teaching hospital were studied to evaluate the utility of autopsy in these populations. Autopsy records of the University of North Carolina hospitals from 1982 to 2001 were reviewed for all patients less than 18 years of age. Autopsies performed during 1982 to 1991 (decade 1) were compared to those from 1992 to 2001 (decade 2) with respect to absolute numbers of autopsy and rates of unexpected postmortem diagnoses. Postmortem diagnostic discrepancies were subclassified into major and minor categories. The mean number of autopsies per year for decade 1 was 110+/-24.5, compared with 77.5+/-40.9 for decade 2 (P<0.001), a change largely due to a decline in fetal/perinatal (patients<7 days of age) autopsies. Of 533 pediatric autopsies, 43 were in patients with a primary diagnosis of a neoplasia. At least one antemortem misdiagnosis and/or clinically occult process was identified in 20.5% of all pediatric autopsy cases, and in 25.6% of pediatric oncology cases. These rates did not change significantly over time. In 10 of 43 pediatric oncology cases (23.3%), autopsies provided diagnostic information that was previously unknown to the clinicians. Three of these patients died shortly after presentation. Although autopsy rates for fetal/perinatal cases have declined, those for non-perinatal and pediatric oncology patients remain stable. Autopsy continues to provide diagnostic information that is unknown during the antemortem period, and remains a valuable tool for pediatricians and pediatric oncologists.
Renal transplantation is considered to be the optimal replacement therapy for children with end-stage renal disease. However, the number of pediatric renal transplants in Japan is much lower than in the USA and/or Europe. Since October 1997, pediatric(< 15 years) recipients are given priority over adult recipients for organ sharing, only if one or two HLA-DR antigen(s) are matched between the recipient and pediatric(< 15 years) donor. However, the number of pediatric transplants is not increasing. One hundred and twenty-four pediatric renal transplantations were performed in Tokyo Women's Medical University between 1983 and 1999, of which 18(14.5%) were cadaveric transplants and the others (106, 85.5%) were living-related transplants. We examined 18 pediatric cadaveric renal transplantations. Seven patients received their graft from pediatric donors less than 15 years of age and 11 from adult donors. The mean age at transplantation was 13.2 years (range 4.5-18.7 years). Major etiologies of renal disease are hereditary renal disease(38.8%), chronic glomerulonephritis(33.3%), and focal segmental glomerulosclerosis[FSGS] (16.7%). Zero matches in HLA-DR locus were observed in 72.2%. Patient survival rate was 100%. Graft survival rates at 1 and 5 years after transplantation were 83% and 64% successively. There was no significant difference between the graft survival of cadaveric and living-related transplantation at 1 and 5 years. All 5 patients who received their graft between 1994 and 1998 have maintained normal graft function. Causes of their graft loss were chronic rejection in 3, recurrence of FSGS in 2, primary non-function in 1, and graft thrombosis in 1. Donor age and HLA-DR mismatching did not affect the outcome. We propose that pediatric renal grafts should be provided to children with priority, regardless of their HLA-A, B and HLA-DR matching.