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PubMed2006

Pediatric resident education in palliative care: a needs assessment.

OBJECTIVE: The goal was to characterize pediatric residents' perceived educational needs for pediatric palliative care. The data generated from this study will facilitate the planning of specific educational interventions. METHODS: All residents in the Children's Hospital of Pittsburgh pediatrics residency program were asked to complete a survey in September 2003. Participation in the study was voluntary. Residents rated their previous training, personal experience, knowledge, competence, and emotional comfort with 10 specific aspects of pediatric palliative care. This rating was followed by 13 questions related to attitudes about palliative care practices and training. The last section asked the respondents to rank 11 palliative care educational topics in order of importance. RESULTS: Forty-nine of 75 eligible residents participated. Although residents thought that pediatricians should have an important role in providing palliative care, residents reported minimal training, experience, knowledge, competence, and comfort in virtually all areas of palliative care for children. We found no significant improvement in any of these areas from the pediatric level-1 year to the pediatric level-3 year. Residents wanted more training regarding pain management. After pain control, the next 4 educational needs were communication skills, namely, discussing prognosis, bad news, and code status and talking with children about end-of-life care. CONCLUSIONS: There is a clear need for increased efforts in pediatric palliative care education during residency training. Pediatric residents do not think that they are trained adequately in palliative care, and this perception does not improve with time. Pediatric residents view palliative care as important for primary care physicians and desire more education.

Internship and Residency↗
PubMed2006

Mental health screening in pediatric practice: factors related to positive screens and the contribution of parental/personal concern.

OBJECTIVES: The goals were to examine factors related to positive Pediatric Symptom Checklist scores in an urban practice and to examine the relative contribution of parental/personal concern about emotional and behavioral problems to mental health problem identification. METHODS: Annual screening using the Pediatric Symptom Checklist was implemented in Cambridge Pediatrics (Cambridge, MA). A social worker was colocated in the clinic to provide therapeutic interventions for patients. A sample of 1668 screened patients between 4 years 11 months and 19 years of age was used for analysis. Bivariate and multivariate analyses were conducted to determine factors predictive of positive Pediatric Symptom Checklist scores, including demographics, socioeconomic indicators, enrollment in counseling, and parental/personal concern. Parental/personal concern, counseling, and positive Pediatric Symptom Checklist scores were examined to determine their efficacy as screening methods. RESULTS: Six percent of the population had positive Pediatric Symptom Checklist scores. There were statistically significant relationships between a positive score and being in counseling, parental/personal concern, having public insurance, and living in an area with median household incomes of less than 50,000 dollars. Parental/personal concern was 40% sensitive for a positive score. A positive Pediatric Symptom Checklist score with or without parental/personal concern identified 3.8% of the population; parental/personal concern with or without a positive Pediatric Symptom Checklist score identified 4.5%. CONCLUSIONS: Mental health screening can be effectively implemented in a pediatric practice. Colocated mental health professionals provide additional support. The combination of a screening tool and questions about parental/personal concern and present counseling can provide critical information about a child's mental health.

Adolescent↗
PubMed2005

Pediatric pharmacotherapeutic education: current status and recommendations to fill the growing need.

The Accreditation Council for Pharmacy Education and the Canadian Council for Accreditation of Pharmacy Programs state that their respective programs should provide a curriculum appropriate to produce general practitioners of pharmacy. Millions of prescriptions are written for infants and children each year, and relatively few pharmacists practice in environments devoid of pediatric patients. To fulfill the stated mandate, professional pharmacy curricula must include adequate content dedicated to pharmaceutical care of the pediatric patient. Current pediatric curricula are inadequate and must be improved. Pediatric topics should be introduced early in the curriculum to increase students' awareness of the special needs of this vulnerable population. Other recommendations include the provision at least 25 hours of didactic instruction in core pediatric areas and at least one pediatric clinical rotation to all students. Pharmaceutical care of pediatric patients can also be improved by offering pediatric rotations to all pharmacy practice residents and encouraging their participation. However, a change in attitude may be most important. The contention that pediatric pharmacy practice is an isolated subspecialty can no longer be supported.

Clinical Competence↗
PubMedDate not supplied

Pediatric travel consultation in an integrated clinic.

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 < or = 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. CONCLUSION: 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.

Adolescent↗
PubMed2001

Epidemiological trends of pediatric emergency referrals in Israel.

BACKGROUND: In the last decade pediatric emergency medicine in Israel advanced to a stage of independent emergency pediatric departments. At the same time, injuries and childhood, trauma--a global health problem--became the main cause of mortality and emergency referrals in children over the age of one year. OBJECTIVE: To determine the extent of pediatric referrals to emergency departments and the rate of pediatric trauma referrals in Israel. METHODS: The records from EDs of Israel's 24 public hospitals for a 6 year period (1994-99) were collected. The records based on computerized ED records were used to identify the basic demographics of pediatric ED referrals. Routine data for all pediatric patients were collected from pediatric and general EDs. This study is an analysis of the accumulated anonymous ED databases. RESULTS: Pediatric referrals to EDs accounted for 2,907,912 patients, 37% of them due to trauma. The mean hospitalization rate was 21%. No significant changes were observed during the 6 years in the rate of pediatric ED referrals and in the ED hospitalization rate of children. There is a constant trend of increase in trauma referrals of children. CONCLUSIONS: The ED is a major site for the delivery of healthcare to children in Israel. One of every four children in the community is referred every year to an ED, and more than one-third of those referrals are due to trauma.

Adolescent↗
PubMed1999

Pediatric research: coming of age in the new millennium.

One of the many provisions of the recently enacted Food and Drug Administration Modernization Act (FDAMA) provides for an additional period of market exclusivity in exchange for completed pediatric studies requested by the FDA for certain drugs of potential benefit to the pediatric population. The impetus for this law centers around two facts: Drugs needed in the pediatric population lack labeling for pediatric use, and industry lacks incentive to perform studies to support this additional labeling. Congress has now provided the incentive. The success of the pediatric initiative will rest initially on industry's willingness and readiness to do the studies. This willingness, in turn, will depend on FDAMA's impact on the economics of drug development and the availability of pediatric research capacity, both of which could be affected by the FDA's final rule on the assessment of safety and effectiveness of drugs and biologicals for pediatric patients. This rule will compel firms to conduct pediatric studies similar to the ones encouraged under FDAMA's voluntary pediatric exclusivity program. Although the Act provides for the statutory harmonization of the rule with the Act, whether the effects of the rule on the Act have been fully contemplated is a premise considered in this article. Congress too has much to contemplate as they evaluate the FDA's report, due in less than 2 years, on the public health effectiveness and economic effects of the Act's incentive program in preparation for possible FDAMA II modifications.

Drug Industry↗
PubMed2001

[Adolescent health care in pediatric departments of Tuscany].

BACKGROUND: Admission to Pediatric Departments for 0/18- year-old patients is an important issue for the best organization of pediatric hospital assistance. Aim of the study. To locate adolescent health care and identify the percentage of adolescent admissions to Pediatric Departments in an Italian region (Tuscany). METHODS: Adolescent health care in pediatric departments and pediatric admissions (0-18 years old) in 1999 into the reference hospital of Pisa and into 5 other regional hospitals in Tuscany are reported. The percentages of patients, subdivided by age, hospitalyzed in Pediatric Departments have been determined. RESULTS: In 1999 the admissions for subjects aged 0 to 18 years were 12573 of which 4966 adolescents (39.6 %). The percentage of adolescent admissions is not smaller than children's admissions (aged 0 to 1 year: 16.2%; aged 2 to 5 years: 26.2%; aged 6 to 9 years: 17.8%; aged 10 to 14 years: 20.4%; aged 15 to 18 years: 19.2%). Analysis by age demonstrated a continuous decrease of patient percentages admitted to Pediatric Departments with the increased age. A minority of 15/18- year-old subjects has been admitted to Pediatric Departments. CONCLUSIONS: The percentage of adolescent admissions is similar to there of children. Most adolescents are admitted to structures unsuitable for assistance to subjects aged 0 to 18 years. These data underline the necessity for a strong recovery of adolescent admissions to pediatric structures also equipping suitable nursing rooms.

Adolescent↗
PubMed2001

Status of pediatric perfusion education: 2000 survey.

In recent years, studies have raised questions about pediatric perfusion training, minimum proficiency requirements, and specialization. To understand these questions better, a survey was undertaken to investigate the status of pediatric/neonatal perfusion training in the United States. Three groups were surveyed: program directors (PD), recent graduates of perfusion programs (RG), and pediatric cardiac anesthesiologists (PCA). Program directors and recent graduates were queried about didactic curriculum and clinical experiences. All three groups were asked core questions regarding minimum proficiency, specialization, and need for a postgraduate style program. Didactically, 65% of program directors believed that perfusion programs provided a solid introductory knowledge base in infant perfusion. Clinically, students performed an average of 124 +/- 42.5 adult and 17 +/- 12.9 pediatric cases during their education. Program directors cited numerous limitations to clinical pediatric education, including access to pediatric cases and allocation of resources. The PD (69%) and RG (96%) both believed graduates were less prepared to perform infant/pediatric cardio-pulmonary bypass (CPB) at graduation as compared to adult CPB. The opinions of all three groups were divided when asked whether the essentials and guidelines requirement for minimum pediatric caseload is too low (yes response: PD 52%, RG 73%, PCA 47%). The PD and RG were against pediatric subspecialization/certification (87%, 57% respectively); whereas, the PCA were unanimously in favor (100%) of pediatric subspecialization/certification for perfusionist. All three groups felt a postgraduate-style program in infant perfusion would benefit the community (78%, 82%, 100%). Finally, 64% of RG said that, if available, they would have considered entering a training program in pediatric/neonatal perfusion after graduation. Our results indicate that there are still limitations to pediatric perfusion education. A postgraduate-style program in infant perfusion is one possible solution to this problem.

Attitude of Health Personnel↗
PubMed2001

[The rise and fall of the general pediatric practitioner in Sweden].

At the end of the 1960s the Minister of Health in Sweden became interested in the way Czechoslovakia had organised the care of both healthy and sick children with one general pediatric practitioner for every 1500 children. After thorough investigation The National Board of Health and Welfare in Sweden proposed that outpatient pediatric care be integrated with health care both of pre-school- and of school children. It was stated by The National Board of Health and Welfare that it would be sufficient with one pediatrician for 2500 children, since highly qualified pediatric nurses were employed both at the well-baby clinics and in the schools. Thus it was calculated that 700 pediatricians would be needed in primary care in Sweden. This proposal was received in a positive way and in many counties it was planned that specialists in pediatrics should be in charge of the children in pediatric outpatient clinics. However, in the aftermath of the events of 1968, the opinion changed during the 1970s. The revolutionary groups that wanted to destruct the society in order to create something new did not want to have reform proposals that they regarded as cosmetics. Science was considered anti-social and professionalism was viewed highly suspect. Specialists were looked down upon, both within the health profession and elsewhere. The institutions and their representatives were not unaffected by these sentiments. The Swedish Medical Association, that from the beginning had applauded the counties that had planned to follow the proposal from The National Board of Health and Welfare, did a right-about turn under the pressure of the general practitioners who did not want to abstain from the children? "this nice group of patients". In 1974 the Swedish Medical Association declared that pediatricians should not be active in primary care. Also The National Board of Health and Welfare became influenced by the spirit of the times and thus, in 1978, decided that a substantially lower number of pediatricians should be trained than they had earlier planned. At that stage, many of the counties changed their plans regarding pediatric care to be benefit of the general practitioners. Altogether well over 200 positions for general pediatric practitioners were established. At the turn of the millennium, this number remains virtually unchanged. Some counties have a very well established pediatric cae, whereas others do not have one single pediatrician employed in the primary health care. However, it presently seems that the general opinion in this regard is changing. There is a growing consciousness that children are in need of professional medical care as the status of children during the 1990s has steadily deteriorated because of e.g. immigrations and increasing social inequalities. Both the Minister of Health and other influential health care politicians have recently claimed the need for pediatricians in primary care. However, during the next few years many of the specialists in pediatrics born during the 1940s will retire. Therefore a substantial expansion of the education and training of pediatricians of utmost importance in order to replace the retired professionals and to fill the needs of primary care.

History of Medicine↗
PubMedDate not supplied

Geographic distribution of pediatric dentists in private practice in the United States.

PURPOSE: The objectives of this study were to: (1) determine the geographic distribution of pediatric dentists in private practice across the United States; and (2) compare state-based pediatric dental practitioner-to-children ratios. METHODS: Enumeration of pediatric dental practitioners was derived from the American Academy of Pediatric Dentistry's 2000-01 Membership Directory by including all active and fellow members who were in private practice in the United States. Population information for the 50 states and District of Columbia was obtained from Census 2000 data available on the US Census Bureau's Web site. RESULTS: A total of 2,913 pediatric dentists were in private practice in the United States, with the largest number located in California (333), Texas (238), and New York (202), and the smallest number located in Maine (3) and North Dakota (4). There were 4.03 pediatric dental practitioners for every 100,000 US children younger than 18 years of age. Connecticut and Massachusetts had almost twice (7.7) as many pediatric dental practitioners per 100,000 children as the national average. On the other hand, Maine had only one fourth (1) the number of pediatric dental practitioners per 100,000 children as the national average. CONCLUSIONS: Marked differences exist between the various states in their pediatric dental practitioner-to-children ratio.

Adolescent↗
PubMedDate not supplied

[Readmission to International Pediatric Association: a review and perspective].

The Pediatric Association of the Republic of China, which was founded in 1960 for the promotion of child health care, research and teaching as well as of friendship among pediatricians, entered the International Pediatric Association (IPA) in May, 1961. This Association actively participated in the 10th to 13th International Congresses of Pediatrics (ICP) held in Lisbon 1962, Tokyo 1965, Mexico City 1968 and Vienna 1971, respectively. It also sent a group of delegates to the Ist Asian Congress of Pediatrics, organized by the Association of Pediatric Societies in South East Asian Region (APSSEAR), held in Manila in 1974. Regretably, this Association was forced out of IPA in October 1973, and APSSEAR in 1974, simply because that the pediatric society of Mainland China had been admitted to the IPA. The members of the Association continued working hard and strived for the excellence in clinical pediatrics. Our members were encouraged to attend the international meetings regardless of membership problems. Some international meetings were organized and held in Taiwan attracting many experts and investigators from abroad. In July 1989, this Association was readmitted to the IPA under the name of "Chinese Taipei", likewise in Olympics, during the 19th ICP, held in Paris. Also granted was the right of voting. Re-admission to the APSSEAR was also approved. With gratitude and rejoice, we commemorate the return to International arena. It is hoped that more expert advices and friendship will come from IPA, WHO, UNICEF, and some member countries. They may help us update clinical practices, and engage in more important surveys and research programmes, such as the international surveys on pediatric education, expanded programmes for immunization, and global accident prevention programmes. They may also help us achieve our unfulfilled tasks, such as pediatric subspecialization, renovation of the births registration system, founding of children's medical centers and health insurance coverage among children. We are now in a better position to advocate the child health care in Taiwan, hoping that health for all including children will be achieved by the year 2000.

Forecasting↗
PubMed1989

Early and final preferences for pediatrics as a specialty: a study of U.S. medical school graduates in 1983.

The early and final specialty preferences for pediatrics made by 10,321 U.S. medical school graduates in 1983 were obtained from the students' responses to the Premedical Student Questionnaire, which accompanied their Medical College Admissions Test, and to the Medical Student Graduation Questionnaire, filled out not long before they graduated from medical school. A total of 11.5% of the women and 5.9% of the men expressed a preference for pediatrics on the earlier questionnaire, when they were premedical students; 13.5% of the women and 4.8% of the men actually chose pediatrics when they were senior medical students, as reflected on the later questionnaire. On both questionnaires, 31.3% of the women's preferences and 14.6% of the men's preferences for pediatrics did not change. More than 70% of all the graduating students choosing pediatrics had expressed a premedical preference for a primary care specialty. Fifty-one percent of the women and 42% of the men who abandoned their early preferences for pediatrics chose another specialty within primary care. More students of both genders shifted from a premedical preference for family practice into pediatrics than kept their early preference for pediatrics. If the direction of change noted in this study and others continues, pediatrics will increasingly become a specialty chosen by women.

Career Choice↗
PubMed1993

Comprehensive pharmaceutical services for pediatric patients.

The development of comprehensive pharmaceutical services for pediatric patients at a tertiary-care teaching hospital is described. A team of three staff pharmacists, a clinical specialist, and supportive personnel was formed. A pediatric pharmacy, operating from 0800 to 2100 daily, was created in a separate area of the central pharmacy to focus on potential problems with pediatric dosage calculations and drug administration. The team staffs the pediatric pharmacy for 75% of its day and evening shifts. The pharmacy prepares the 24-hour unit dose supply for each nursing unit, processes new orders, and provides drug information and problem-solving services. Clinical services are provided by the decentralized pharmacist, a rotating member of the team who makes rounds each day to the pediatric nursing units to review patient charts, provide medication information, and answer questions. The pediatric clinical specialist conducts educational programs, provides consultations, maintains reference materials, monitors pharmacokinetic evaluations, reviews medication communication forms, and assists in developing medication administration procedures. The creation of a pediatric pharmacy and a pediatric pharmacy team that coordinates both dispensing and clinical functions has made it possible to provide comprehensive pharmaceutical services to pediatric patients.

Child, Preschool↗
PubMedDate not supplied

Publication potential in pediatrics in Turkey.

In this article, the publication potential in pediatrics in Turkey was investigated. In this context, native pediatric journals, publication activities of medical faculties as the main source of scientific publication and certain data obtained from some of the international indexes' sources were analyzed. The Turkish Journal of Pediatrics (Turk J Pediatr) and Cocuk Sağliği ve Hastaliklari Dergisi are two native pediatric journals which have been published without interruption for 36 and 37 years, respectively. Both are indexed in BIOSIS (Bioscience information Service) and Excerpta Medica. In addition, Turk J Pediatr is indexed in Index Medicus and Current Contents, and is the only Turkish medical journal indexed in Index Medicus at present. Eighty percent of papers submitted to both journals are from medical faculties all over the country (60% of these from Hacettepe Faculty of Medicine), while 15% are from the teaching hospitals of the Ministry of Health and 5% from outside the country. In 1994, Hacettepe University School of Medicine was the leader with 244 (21%) of the 1165 articles published in the health sciences from 22 medical faculties in Turkey. In the same year, 32 percent of all International medical publications by Hacettepe Faculty of Medicine were in the field of pediatrics. In addition, of 353 papers by Turkish authors appearing in Current Contents during the three-month period July-September 1993, 70 (20%) were pediatric articles. All of these findings may indicate that publications in the field of pediatrics have increasing potential and an important impact on the scientific medical publication's platform in our country.

Humans↗
PubMed1997

Effect of a monitored care unit on resource utilization in a pediatric ICU.

OBJECTIVE: To determine the effect of a monitored care unit on resource utilization in a pediatric ICU. METHODS: The study was done at a 205-bed pediatric medical center located in northern California. Efficiency of resource utilization in the pediatric ICU was evaluated by comparing the following factors before and after the implementation of a monitored care unit: (1) efficiency in the pediatric ICU, (2) number of patients turned away for lack of beds, (3) hours of nursing care per patient day, and (4) cost (as estimated from charge ratios) in the monitored care unit for care of patients admitted because of some common reasons. RESULTS: Efficiency in the pediatric ICU increased significantly after implementation of a monitored care unit. The number of patients not admitted to the pediatric ICU because not enough beds were available was identical before and after establishment of the monitored care unit. After the monitored care unit was established, hours of nursing care per patient day were significantly reduced, enabling the number of patient days to be increased without increasing cost. In addition, cost comparisons showed a decrease in both length of stay and total cost per admission for patients undergoing ventriculoperitoneal shunt revision and lambdoidal suture synostectomy. CONCLUSIONS: Use of beds in the pediatric ICU was more efficient when a high-observation setting was available for low-risk monitored patients. Key differences in patterns of use were observed. Compared with the pediatric ICU, the monitored care unit requires fewer personnel and less expensive equipment and supplies, but it still allows potentially life-threatening complications to be recognized and treated. For patients who meet its admission criteria, the monitored care unit is a safe alternative to the pediatric ICU.

Adolescent↗
PubMed1998

Physician bias during patient selection in the pediatric emergency department.

STUDY OBJECTIVES: To evaluate whether pediatric or emergency medicine residents exhibit a bias when they select patients from triage based on the chief complaint, ie, medical versus surgical in the pediatric emergency department (PED). DESIGN: A retrospective chart review of a convenience sample of consecutive patients, excluding those seen during times when both pediatric and emergency medicine residents were not simultaneously present. SETTING: Urban Municipal PED with 25,000 visits annually. TYPE OF PARTICIPANTS: Pediatric residents, emergency medicine residents, and medical students rotating through the PED and their supervising attending physicians. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Five hundred and ninety-nine charts were included in the study. On the basis of the triage complaint the initial diagnosis was classified as either surgical or medical. Surgical diagnoses were assigned to those patients who required a surgical procedure, involved a surgical subspecialty or were victims of trauma and represented 151 (25.2%) of the patients seen. Medical diagnoses were assigned to the nonsurgical patients and represented 448 (74.8%) of the patients seen. There are roughly three pediatric residents to each emergency resident working in our PED. Of the 367 patients seen by the pediatric residents, 73 (19.9%) had surgical diagnoses, and 294 (80.1%) had medical diagnoses. Of the 158 patients seen by the emergency residents, 59 (37.3%) had surgical diagnoses and 99 (62.7%) had medical diagnoses. chi2 analysis was used to compare categorical variables. The P value was considered significant at <0.05. DISCUSSION: Residents, both pediatric and emergency medicine, were instructed to see patients based upon the severity of the patient illness as judged by the triage nurse unless the patients' illnesses were of equal severity, in which case they were to be seen in the order in which they presented. The null hypothesis was that in the absence of physician bias, both pediatric and emergency medicine residents would see the same proportion of surgical and medical patients. The results showed that a bias exists. Emergency medicine residents saw a greater proportion of surgical patients, and pediatric residents saw a greater proportion of general medical patients. A limitation of this study may be the that the supervising attending physician selected residents to see certain patients to expedite PED flow. CONCLUSIONS: Recognizing that bias in the selection of patients seen exists is important in ensuring a balanced education experience.

Child↗
PubMed2005

Antiretroviral treatment in pediatric HIV infection in the United States: from clinical trials to clinical practice.

CONTEXT: Antiretroviral therapy (ART) for pediatric human immunodeficiency virus (HIV) infection has evolved from simple nucleoside reverse transcriptase inhibitor (NRTI) regimens to complex combination therapies based largely on evidence from clinical trials. However, the integration of novel ART into the clinical care of pediatric HIV infection has not been examined. OBJECTIVES: To describe changes in the treatment of pediatric HIV infection in the United States from 1987-2003, to assess concordance of initial regimens with US pediatric guidelines, and to identify predictors of the first regimen switch. DESIGN, SETTING, AND PARTICIPANTS: The study population included 766 perinatally HIV-infected children in the Pediatric AIDS Clinical Trials Group 219C cohort born before January 1, 2004, who had not participated in an ART clinical trial at 219C enrollment or during follow-up. MAIN OUTCOME MEASURES: Proportion of children receiving specific ART regimens, proportion of children initiating ART according to pediatric guidelines, and time to first regimen switch (risk of switching). RESULTS: Single and dual NRTI regimens were used most frequently through 1997. In 1998, 2 years after protease inhibitors were approved for adult HIV infection and at the time pediatric guidelines were issued, regimens of highly active antiretroviral therapy including a protease inhibitor became most frequently used. From 1998-2003, 22% of children initiated ART with a regimen not recommended by pediatric guidelines. In multivariate regression, the risk of switching decreased with age at ART initiation (hazard ratio [HR], 0.96; 95% confidence interval [CI], 0.94-0.99) and increased with year of initiation (HR, 1.28; 95% CI, 1.23-1.33). The risk of switching was higher in children who started with 1 NRTI (HR, 8.05; 95% CI, 5.80-11.18), 2 NRTIs (HR, 4.08; 95% CI, 3.08-5.40), or an unconventional regimen (HR, 6.23; 95% CI, 3.36-11.54) vs children who started with a protease inhibitor-containing regimen; and in children who initiated ART at CD4 T lymphocyte percentages less than 15 vs 15 or greater (HR, 2.90; 95% CI, 1.03-8.13). CONCLUSIONS: There was a short lag between the identification of novel ART and its adoption in the pediatric community. A variety of regimens were used, including some unorthodox therapies. Important predictors of first regimen switch were identified.

Adolescent↗
PubMed2005

Comparison of two new classifications for pediatric myelodysplastic and myeloproliferative disorders.

BACKGROUND: The category, cytology, cytogenetics (CCC) system for myelodysplastic syndrome (MDS) and the pediatric WHO system for MDS/myeloproliferative disorder (MPD) have recently been proposed to characterize these diseases in pediatrics. OBJECTIVE: We compare the CCC and pediatric WHO systems against each other and against the French, American, British (FAB) and adult WHO classifications in order to determine which more accurately classifies these diseases and predicts outcome. METHODS: An 18-year retrospective review identified patients less than 18 years of age meeting CCC and/or pediatric WHO criteria for the diagnosis of MDS or MPD. Resolution, stability, progression, and death in the subcategories of each system were compared. RESULTS: Twenty-eight patients were included in the study. Pediatric WHO: 17 patients met criteria, 10 died. Eight developed acute myelogenous leukemia (AML) (seven died), one juvenile myelomonocytic leukemia (JMML) (died), one chronic myelomonocytic leukemia (CMML) (currently in relapse), two died of complications, two responded to BMT, three have stable disease, one resolved. Eleven patients were not classifiable by the pediatric WHO system, one of which progressed to AML and died. CCC: 26 patients met criteria, 9 died. Nine developed AML (8 died), 1 died of complications, 10 responded to treatment (BMT and/or chemotherapy). Four are stable without treatment, two resolved. Two patients with MPD were not classifiable by the CCC system. CONCLUSIONS: Both the pediatric WHO and CCC systems are better able to classify MDS in children than the adult WHO and FAB classifications. The pediatric WHO system is more exclusive. Children meeting these criteria are more likely to progress to AML or death. The restrictive nature of the pediatric WHO system was unable to classify one case of fatal MDS. The CCC system is more inclusive and can stratify patients into a neutral or poor prognosis based upon outcome. However, the CCC system ignores those diseases with a myeloprolifferative component. This resulted in two cases of MPD that were unclassifiable by the CCC system. One of these patients died, the other is currently in relapse.

Adult↗