Creation of a Novel Child Simulator and Curriculum to Optimize Administration of Seizure Rescue Medication

INTRODUCTION

Although most cases of pediatric convulsive status epilepticus start in the prehospital setting, many patients do not receive treatment. The use of prehospital seizure rescue medications by caregivers is crucial, but studies suggest a lack of proper training on medication use.

METHODS

We created a novel proof of principle mannequin and simulation for training proper administration of rectal diazepam, with a scoring paradigm to standardize and assess the educational process.

RESULTS

Twenty-three health care providers (nurses and nurse practitioners, residents/fellows, and attending physicians) and 5 patient guardians/parents were included in the study. The rectal diazepam simulator displayed a high degree of physical and emotional realism (mean ≥ 4/5 on Likert scale survey) that effectively decreased time to treatment (-12.3 seconds; SD, 16.3) and improved the accuracy of medication delivery in a simulation setting (-4.2 points; SD, 3.1). The scoring technique had appropriate interrater reliability (≥86% on all but 2 prompts) and was a feasible instrument to assess the effectiveness of the educational intervention.

CONCLUSIONS

A unique procedure-focused child simulator and rescue medication score offer an innovative and effective means to train caregivers on the use of lifesaving seizure rescue medications.

Special Education Services and School-Related Quality of Life in Children With Learning Disorders and Their Families: A One-Year Follow-Up Study

Learning disorders can have adverse impacts on children and families extending beyond the academic skills deficits. The goal of the present study was to assess the impact of the school's response, following an independent evaluation, for child and family school-related quality of life (QOL). We hypothesized that a positive school response would be associated with improved QOL. Parents completed the LDQOL/15, a brief measure of school-related QOL, at the time that their child received an independent evaluation and again a year later (N = 155). At follow-up, parents reported the tenor of the school's response to the evaluation and whether special education services had changed. QOL problems were very high in this referred population, with 66% of respondents rating a level of problems in the clinical range at baseline. Predicted interactions between time of assessment (baseline/follow-up) and the school's response to the evaluation were confirmed for all outcome variables; a positive school response was associated with improved QOL. Nevertheless, the overall prevalence of school-related QOL problems remained high a year after the evaluation. These findings indicate that special education interventions can mitigate learning disabilities' impacts, but even with these services, many children with learning disorders and their families continue to be significantly affected.

Feasibility and Effect of Reiki on the Physiology and Self-perceived Stress of Nurses in a Large US Hospital

Nurses experience stress in the workplace. We evaluated the feasibility and effect of Reiki to relieve stress of staff nurses during a work shift. All Reiki treatments were completed without interruption and lasted 30 minutes. Stress scores, respiratory rate, and heart rate were significantly decreased immediately following the Reiki treatment.

Evaluation of an evidence-based practice mentorship programme in a paediatric quaternary care setting

BACKGROUND

Evidence-based practice (EBP) is essential for clinical decision-making, improving care, reducing costs and achieving optimal patient outcomes. The Evidence-based Practice Mentorship Program (EBPMP) is a flexible, self-directed programme whereby participants carry out EBP projects guided by expert mentors.

AIMS

To evaluate EBPMP effectiveness and participant experience.

METHODS

To evaluate effectiveness, as measured by changes in EBP value, knowledge and implementation, participants completed pre- and post-EBPMP Quick-EBP-Value, Implementation and Knowledge (VIK) surveys. To understand participants' experiences individual and group interviews were conducted at the end of the programme and analysed using qualitative content analysis.

RESULTS

Most participants were over 50 years old, Caucasian, inpatient staff nurses, baccalaureate prepared, with over 11 years' experience. Statistically significant improvements were observed in the post Quick-EBP-VIK knowledge and implementation domains. Individual and group participant interviews revealed four categories of importance to the experience: 1. perceived benefits of EBP, 2. time as a barrier to EBP, 3. desire for more cohort interaction and 4. positive mentee-mentor experience.

CONCLUSIONS

EBPMP can improve participants' knowledge and implementation of EBP in an environment that values EBP; however, opportunities exist to implement programme modifications that address barriers identified by participants including project time and increased participant interactions.

Validation of the Hospital Asthma Severity Score (HASS) in children ages 2-18 years old

INTRODUCTION

The Hospital Asthma Severity Score (HASS) was developed to communicate inpatient asthma severity between providers. The purpose of this prospective study was to validate the HASS against the Pediatric Respiratory Assessment Measure (PRAM) and spirometry for assessment of inpatient asthma exacerbation severity in patients 2-18 years old, at a single point-in-time.

METHODS

This study was registered with clinicaltrials.gov (NCT02782065). Children admitted to a tertiary care, free-standing children's hospital were assessed for asthma severity using the HASS, PRAM, and pulmonary function by spirometry. Inter-rater agreement of HASS and PRAM scores was assessed between two blinded clinician raters. Spirometry results were obtained by a certified pulmonary laboratory technician and correlated with HASS and PRAM scores.

RESULTS

The sample included 58 subjects. Allowing for a one-point difference in continuous HASS and PRAM scores, inter-rater agreement was 79% for the HASS and 60% for the PRAM. When the scores were categorized as mild, moderate, and severe, inter-rater agreement was 62% for the HASS and 93% for the PRAM (p < .0001). Additionally, intra-rater agreement between HASS and PRAM severity categories was 71% for Rater 1 and 64% for Rater 2. A weak correlation was noted between both the HASS and FEV₁ (r = -0.31; p = 0.11), and PRAM and FEV₁ (r = -0.30; p = 0.11) for the 29 subjects with acceptable spirometry results.

CONCLUSIONS

The HASS and PRAM have acceptable inter-rater and intra-rater agreement. These results support validation of the HASS for managing hospitalized patients during asthma exacerbations.

Health Care Transition in Type 1 Diabetes: Perspectives of Diabetes Care and Education Specialists Caring for Young Adults

PURPOSE

The purpose of the study was to describe experiences reported by diabetes care and education specialists caring for young adults with type 1 diabetes and to assess perceived deficiencies in clinical resources and barriers to care delivery.

METHODS

A 60-item electronic survey was fielded through email to members of the Association of Diabetes Care and Education Specialists (ADCES). Respondents completed a survey consisting of: (1) clinical practice characteristics and respondents' demographics; (2) health care transition components (eg, referrals) and their perceived importance; (3) framework of current clinical diabetes care delivery and perceived need for additional support; and (4) perceived barriers regarding clinical care delivery. Statistical analyses included descriptive statistics, chi-square tests, and logistic regression.

RESULTS

Respondents (N = 531, 96% female, median years in practice = 13; interquartile range = 7-20) represented 49 states plus the District of Columbia. Although 88% of respondents reported reviewing pediatric records as important/very important, only 22% often/always reviewed them. Although 58% of respondents noted easy access to mental health care providers for young adults, 50% stated a need for additional resources. Furthermore, diabetes care and education specialists without easy access to mental health professionals were significantly more likely to report barriers to diabetes management for young adults with depression, substance abuse, eating disorders, and developmental disabilities.

CONCLUSION

Study findings highlight modifiable factors that may improve diabetes care coordination for transitioning young adults. Uniform approaches and increased access to trained mental health professionals may help support diabetes care and education specialists in their care of young adults with type 1 diabetes.

Fatigue in children and adolescents with immune thrombocytopenia

Immune thrombocytopenia (ITP), an acquired autoimmune disorder of low platelets and risk of bleeding, has a substantial impact on health-related quality of life (HRQoL). Patients with ITP often report significant fatigue, although the pathophysiology of this is poorly understood. In this observational cohort of 120 children receiving second-line therapies for ITP, we assessed reports of fatigue using the Hockenberry Fatigue Scale. Children and adolescents with ITP reported a similarly high level of fatigue with 54% (29/54) of children and 62% (26/42) of adolescents reporting moderate-to-severe fatigue. There was no correlation between fatigue and age or gender. Adolescents with newly diagnosed and persistent ITP had higher mean fatigue scores than those with chronic ITP (P = 0·03). Fatigue significantly improved in children and adolescents by 1 month after starting second-line treatments, and this improvement continued to be present at 12 months after starting treatment. Fatigue scores at all time-points correlated with general HRQoL using the Kids ITP Tool, but did not correlate with bleeding symptoms, platelet count, or platelet response to treatment. Fatigue is common in children and adolescents with ITP and may benefit from ITP-directed treatment even in the absence of bleeding symptoms.

Association of Blood Type With Postsurgical Mucosal Bleeding in Pediatric Patients Undergoing Tonsillectomy With or Without Adenoidectomy

IMPORTANCE

Blood type (BT) O has been identified as a risk factor for bleeding complications, while non-O BTs may increase risk for thromboembolic events. Limited data are available in children undergoing tonsillectomy with or without adenoidectomy.

OBJECTIVE

To determine whether BT O is associated with hemorrhage after tonsillectomy with or without adenoidectomy.

DESIGN, SETTING, AND PARTICIPANTS

Retrospective cohort study of patients younger than 22 years who underwent tonsillectomy with or without adenoidectomy at a single institution between January 1, 2008, and August 7, 2017. Statistical analysis was performed from November 2017 to January 2019.

MAIN OUTCOMES AND MEASURES

Prevalence of hemorrhage following surgery was defined as any bleeding requiring cauterization up to 1 month after the procedure. Data on sex, age, von Willebrand disease (VWD) status, BT, white blood cell counts, and platelet counts closest to date of surgery were collected from an electronic medical record system, and the association of these factors with hemorrhage following surgery was investigated.

RESULTS

A total of 14 951 pediatric patients (median [range] age, 5.6 [0.8-21.9] years; 6956 [46.5%] female) underwent tonsillectomy with or without adenoidectomy. Prevalence of hemorrhage following the procedure was 3.9% (578 patients) for the full cohort and 2.8% (362 of 13 065) for patients with no BT identified or preprocedure VWD panel results at baseline. Children who had a BT identified and/or a VWD panel before surgery had higher bleeding rates (BT only, 14.9% [172 of 1156]; preprocedure VWD panel only, 4.6% [28 of 607]; and BT and preprocedure VWD panel, 13.0% [16 of 123]), all of which were significantly different from the baseline bleeding rate (P < .001). While the bleeding rates in children with BT O were not statistically different from those with non-O BT (14.8% and 14.6%, respectively; P > .99), mean von Willebrand factor values were statistically different (mean [SD] von Willebrand factor antigen level in O group, 86.9 [42.4] IU/dL in the O group vs 118.0 [53.8] IU/dL in the non-O group; P = .002; and mean [SD] von Willebrand factor ristocetin-cofactor in the O group, 72.2 [44.3] IU/dL vs 112.6 [68.0] IU/dL in the non-O group; P = .001). In addition, children older than 12 years had increased bleeding rates in the full cohort (8.3% vs 3.2%), in the testing-naive cohort (6.5% vs 2.3%), and in those with a preprocedure VWD panel only (13.5% vs 3.1%) compared with children aged 12 years or younger.

CONCLUSIONS AND RELEVANCE

Type O blood was not a risk factor associated with hemorrhage after tonsillectomy with or without adenoidectomy despite lower baseline von Willebrand factor antigen and von Willebrand factor ristocetin-cofactor values in children with BT O vs those with non-O BT in our study cohort. No association was found between VWD status and bleeding, and there was no difference in VWD panel values in those who experienced hemorrhage vs those who did not within BT groups. Further studies elucidating the utility of von Willebrand factor values for children undergoing tonsillectomy with or without adenoidectomy are needed.

Macronutrient Analysis of Modified-Fat Breast Milk Produced by 3 Methods of Fat Removal

BACKGROUND

Infants with chylothorax after congenital heart disease surgery are commonly treated using modified-fat breast milk. The effect of fat removal on breast milk macronutrients remains unclear. We compared macronutrient content of breast milk with breast milk skimmed using 3 methods, including a novel device, a cream separator.

METHODS

Thawed frozen breast milk samples from 30 women were defatted using refrigerated centrifuge, cream separator, and manual separation after refrigeration. We used standard assays to measure energy, protein, and fat content of breast milk samples.

RESULTS

All fat removal methods yielded skimmed breast milk with substantially lower fat and energy content. Mean energy content in breast milk skimmed by centrifuge (36.7 [SD 3.6] kcal/100 mL) was similar to that from cream separator (38.8 [3.5] kcal/100 mL). Both centrifuge and cream separator methods removed almost all fat and substantially more fat than the manual fat removal method. For unprocessed milk, energy and fat content estimated by creamatocrit was similar to reference method measurements; in skimmed milk, the creamatocrit significantly overestimated fat content. Mean protein content of skimmed breast milk was similar to unprocessed breast milk (mean 1.25 [0.31] g/100 mL).

CONCLUSION

Breast milk fat removal did not significantly alter protein levels. In skimmed breast milk, the overestimation of fat content using creamatocrit method suggests a need for more accurate bedside methods to assess macronutrient content. The similar macronutrient composition of breast milk skimmed by cream separator and centrifuge suggests the potential for cream separator use as a new, portable defatting method for hospitals and families.

Investigating Potential Biomarkers in Autism Spectrum Disorder

Background

Early identification and treatment of individuals with autism spectrum disorder (ASD) improves outcomes, but specific evidence needed to individualize treatment recommendations is lacking. Biomarkers that could be routinely measured within the clinical setting could potentially transform clinical care for patients with ASD. This demonstration project employed collection of biomarker data during regular autism specialty clinical visits and explored the relationship of biomarkers with clinical ASD symptoms.

Methods

Eighty-three children with ASD, aged 5–10 years, completed a multi-site feasibility study integrating the collection of biochemical (blood serotonin, urine melatonin sulfate excretion) and clinical (head circumference, dysmorphology exam, digit ratio, cognitive and behavioral function) biomarkers during routine ASD clinic visits. Parents completed a demographic survey and the Aberrant Behavior Checklist-Community. Cognitive function was determined by record review. Data analysis utilized Wilcoxon two-sample tests and Spearman correlations.

Results

Participants were 82% male, 63% White, 19% Hispanic, with a broad range of functioning. Group means indicated hyperserotonemia. In a single regression analysis adjusting for race and median household income, higher income was associated with higher levels of blood serotonin and urine melatonin sulfate excretion levels (p = 0.004 and p = 0.04, respectively). Melatonin correlated negatively with age (p = 0.048) and reported neurologic problems (p = 0.02). Dysmorphic status correlated with higher reported stereotyped behavior (p = 0.02) and inappropriate speech (p = 0.04).

Conclusion

This demonstration project employed collection of multiple biomarkers, allowed for examination of associations between biochemical and clinical measures, and identified several findings that suggest direction for future studies. This clinical research model has promise for integrative biomarker research in individuals with complex, heterogeneous neurodevelopmental disorders such as ASD.

Second-line treatments in children with immune thrombocytopenia: Effect on platelet count and patient-centered outcomes

Immune thrombocytopenia (ITP) is an autoimmune bleeding disorder with isolated thrombocytopenia and hemorrhagic risk. While many children with ITP can be safely observed, treatments are often needed for various reasons, including to decrease bleeding, or to improve health related quality of life (HRQoL). There are a number of available second-line treatments, including rituximab, thrombopoietin-receptor agonists, oral immunosuppressive agents, and splenectomy, but data comparing treatment outcomes are lacking. ICON1 is a prospective, multi-center, observational study of 120 children starting second-line treatments for ITP designed to compare treatment outcomes including platelet count, bleeding, and HRQoL utilizing the Kids ITP Tool (KIT). While all treatments resulted in increased platelet counts, romiplostim had the most pronounced effect at 6 months (P = .04). Only patients on romiplostim and rituximab had a significant reduction in both skin-related (84% to 48%, P = .01 and 81% to 43%, P = .004) and non-skin-related bleeding symptoms (58% to 14%, P = .0001 and 54% to 17%, P = .0006) after 1 month of treatment. HRQoL significantly improved on all treatments. However, only patients treated with eltrombopag had a median improvement in KIT scores at 1 month that met the minimal important difference (MID). Bleeding, platelet count, and HRQoL improved in each treatment group, but the extent and timing of the effect varied among treatments. These results are hypothesis generating and help to improve our understanding of the effect of each treatment on specific patient outcomes. Combined with future randomized trials, these findings will help clinicians select the optimal second-line treatment for an individual child with ITP.

Disparities in the delivery of pediatric oncology nursing care by country income classification: International survey results

BACKGROUND

In 2014, a task force of the International Society of Paediatric Oncology (SIOP) Paediatric Oncology in Developing Countries Nursing Workgroup published six baseline standards to provide a framework for pediatric oncology nursing care in low- and lower-middle income countries (L/LMIC). We conducted an international survey in 2016-2017 to examine the association between country income level and nurses' resporting of conformity to the standards at their respective institutions.

PROCEDURE

Data from a cross-sectional web-based survey completed by nurses representing 54 countries were analyzed (N = 101). Responses were clustered by relevance to each standard and compared according to the 2017 World Bank-defined country income classification (CIC) of hospitals.

RESULTS

CIC and nurse-to-patient ratios in inpatient wards were strongly associated (P < 0.0001). Nurses in L/LMIC prepared chemotherapy more often (P < 0.0001) yet were less likely to have access to personal protective equipment such as nitrile gloves (P = 0.0007) and fluid-resistant gowns (P = 0.011) than nurses in high-resource settings. Nurses in L/LMIC were excluded more often from physician/caregiver meetings to discuss treatment options (P = 0.04) and at the time of diagnosis (P = 0.002). Key educational topics were missing from nursing orientation programs across all CICs. An association between CIC and the availability of written policies (P = 0.009) was found.

CONCLUSIONS

CIC and the ability to conform to pediatric oncology baseline nursing standards were significantly associated in numerous elements of the baseline standards, a likely contributor to suboptimal patient outcomes in L/LMIC. To achieve the goal of high-quality cancer care for children worldwide, nursing disparities must be addressed.

Physician decision making in selection of second-line treatments in immune thrombocytopenia in children

Immune thrombocytopenia (ITP) is an acquired autoimmune bleeding disorder which presents with isolated thrombocytopenia and risk of hemorrhage. While most children with ITP promptly recover with or without drug therapy, ITP is persistent or chronic in others. When needed, how to select second-line therapies is not clear. ICON1, conducted within the Pediatric ITP Consortium of North America (ICON), is a prospective, observational, longitudinal cohort study of 120 children from 21 centers starting second-line treatments for ITP which examined treatment decisions. Treating physicians reported reasons for selecting therapies, ranking the top three. In a propensity weighted model, the most important factors were patient/parental preference (53%) and treatment-related factors: side effect profile (58%), long-term toxicity (54%), ease of administration (46%), possibility of remission (45%), and perceived efficacy (30%). Physician, health system, and clinical factors rarely influenced decision-making. Patient/parent preferences were selected as reasons more often in chronic ITP (85.7%) than in newly diagnosed (0%) or persistent ITP (14.3%, P = .003). Splenectomy and rituximab were chosen for the possibility of inducing long-term remission (P < .001). Oral agents, such as eltrombopag and immunosuppressants, were chosen for ease of administration and expected adherence (P < .001). Physicians chose rituximab in patients with lower expected adherence (P = .017). Treatment choice showed some physician and treatment center bias. This study illustrates the complexity and many factors involved in decision-making in selecting second-line ITP treatments, given the absence of comparative trials. It highlights shared decision-making and the need for well-conducted, comparative effectiveness studies to allow for informed discussion between patients and clinicians.

Quality of Life in Children and Adolescents With Learning Problems: Development and Validation of the LD/QOL15 Scale

Learning problems (LP) can have wider implications than the academic deficits per se. The goal of the present series of studies was to develop a reliable and valid quality-of-life measure targeted to children and adolescents with LP. In Study 1, using a 35-item questionnaire, we surveyed 151 parents/guardians of children referred for assessment of learning disorders. Exploratory factor analysis identified a three-factor model: Academic Performance, School Understanding, and Child/Family Psychological. These factors were validated against standardized measures of academic achievement and psychosocial functioning. The questionnaire was then reduced to 15 items-the LD/QOL15 -and administered to a community sample of 325 parents/guardians of children in Grades 1 to 8 (Study 2). The three-factor model was verified with confirmatory factor analysis. Comparison of general education ( n = 232) and LP ( n = 93) groups within the community sample documented substantial group differences ( p < .0001), with the LP group having higher mean scores. These differences were larger for older students (Grades 5-8) than younger students (Grades 1-4; p < .01). The LD/QOL15 is a brief and reliable measure that is valid to assess quality of life and, potentially, outcomes in children and adolescents with LP.

Validation of a pediatric early warning system for hospitalized pediatric oncology patients in a resource-limited setting

BACKGROUND

Pediatric oncology patients are at high risk of clinical deterioration, particularly in hospitals with resource limitations. The performance of pediatric early warning systems (PEWS) to identify deterioration has not been assessed in these settings. This study evaluates the validity of PEWS to predict the need for unplanned transfer to the pediatric intensive care unit (PICU) among pediatric oncology patients in a resource-limited hospital.

METHODS

A retrospective case-control study comparing the highest documented and corrected PEWS score before unplanned PICU transfer in pediatric oncology patients (129 cases) with matched controls (those not requiring PICU care) was performed.

RESULTS

Documented and corrected PEWS scores were found to be highly correlated with the need for PICU transfer (area under the receiver operating characteristic, 0.940 and 0.930, respectively). PEWS scores increased 24 hours prior to unplanned transfer (P = .0006). In cases, organ dysfunction at the time of PICU admission correlated with maximum PEWS score (correlation coefficient, 0.26; P = .003), patients with PEWS results ≥4 had a higher Pediatric Index of Mortality 2 (PIM2) (P = .028), and PEWS results were higher in patients with septic shock (P = .01). The PICU mortality rate was 17.1%; nonsurvivors had higher mean PEWS scores before PICU transfer (P = .0009). A single-point increase in the PEWS score increased the odds of mechanical ventilation or vasopressors within the first 24 hours and during PICU admission (odds ratio 1.3-1.4).

CONCLUSIONS

PEWS accurately predicted the need for unplanned PICU transfer in pediatric oncology patients in this resource-limited setting, with abnormal results beginning 24 hours before PICU admission and higher scores predicting the severity of illness at the time of PICU admission, need for PICU interventions, and mortality. These results demonstrate that PEWS aid in the identification of clinical deterioration in this high-risk population, regardless of a hospital's resource-level. Cancer 2017;123:4903-13. © 2017 American Cancer Society.

Determinants of physical activity frequency and provider advice during pregnancy

Background

Our aims were to (1) describe the frequency of physical activity and prenatal healthcare provider advice about physical activity during pregnancy and (2) examine determinants and correlates of 3rd trimester physical activity and receipt of physical activity advice.

Methods

We analyzed data from the 2008 Pregnancy Risk Assessment Monitoring System. We studied 2669 women from North Carolina and Colorado with data on physical activity frequency in the 3 months prior to pregnancy and during the 3rd trimester and 1584 women from Oklahoma with data on provider advice regarding physical activity during pregnancy. Respondents reported physical activity, defined as 30 min or more of exercise/physical activity (excluding vocationally related activity), in in these categories: <1 day/week, 1-4 days/week, and ≥5 days/week. We defined adherence to American College of Obstetrics & Gynecology (ACOG) criteria as physical activity ≥5 days/week in the 3rd trimester. We performed logistic regression analyses weighted for sampling and adjusted for socio-demographic factors.

Results

Forty-two percent of women in North Carolina and Colorado reported 3rd trimester physical activity <1 day/week, 42% 1-4 days/week, 9% ≥5 days/week; 7% reported being told not to exercise. Seventy-two percent of women in Oklahoma reported receiving physical activity advice from a prenatal care provider. Low activity frequency (<1 day/week) prior to pregnancy was strongly associated with low likelihood of ACOG guideline adherence in the 3rd trimester (aOR 0.10, 95% CU 0.04, 0.30 vs. 1–4 days/week). Underweight women were more likely to adhere to ACOG guidelines than normal weight women (aOR 2.27, 95% CI 1.36, 3.79). Overweight women were more likely to receive physical activity advice (aOR 2.9, 95% CI 1.3, 6.3 vs. normal weight), but obese women were not (aOR 0.65, 95% CI 0.4, 1.2).

Conclusions

Few women meet ACOG guideline criteria for physical activity during pregnancy. Improving physical activity and weight status prior to pregnancy may improve activity levels during pregnancy. Nearly one third did not receive advice about physical activity during prenatal care. Obese women were no more likely to receive advice than their normal weight counterparts, indicating the need for targeted physical activity counseling in this population.

Creation of a novel simulator for minimally invasive neurosurgery: fusion of 3D printing and special effects

OBJECTIVE Recent advances in optics and miniaturization have enabled the development of a growing number of minimally invasive procedures, yet innovative training methods for the use of these techniques remain lacking. Conventional teaching models, including cadavers and physical trainers as well as virtual reality platforms, are often expensive and ineffective. Newly developed 3D printing technologies can recreate patient-specific anatomy, but the stiffness of the materials limits fidelity to real-life surgical situations. Hollywood special effects techniques can create ultrarealistic features, including lifelike tactile properties, to enhance accuracy and effectiveness of the surgical models. The authors created a highly realistic model of a pediatric patient with hydrocephalus via a unique combination of 3D printing and special effects techniques and validated the use of this model in training neurosurgery fellows and residents to perform endoscopic third ventriculostomy (ETV), an effective minimally invasive method increasingly used in treating hydrocephalus. METHODS A full-scale reproduction of the head of a 14-year-old adolescent patient with hydrocephalus, including external physical details and internal neuroanatomy, was developed via a unique collaboration of neurosurgeons, simulation engineers, and a group of special effects experts. The model contains "plug-and-play" replaceable components for repetitive practice. The appearance of the training model (face validity) and the reproducibility of the ETV training procedure (content validity) were assessed by neurosurgery fellows and residents of different experience levels based on a 14-item Likert-like questionnaire. The usefulness of the training model for evaluating the performance of the trainees at different levels of experience (construct validity) was measured by blinded observers using the Objective Structured Assessment of Technical Skills (OSATS) scale for the performance of ETV. RESULTS A combination of 3D printing technology and casting processes led to the creation of realistic surgical models that include high-fidelity reproductions of the anatomical features of hydrocephalus and allow for the performance of ETV for training purposes. The models reproduced the pulsations of the basilar artery, ventricles, and cerebrospinal fluid (CSF), thus simulating the experience of performing ETV on an actual patient. The results of the 14-item questionnaire showed limited variability among participants' scores, and the neurosurgery fellows and residents gave the models consistently high ratings for face and content validity. The mean score for the content validity questions (4.88) was higher than the mean score for face validity (4.69) (p = 0.03). On construct validity scores, the blinded observers rated performance of fellows significantly higher than that of residents, indicating that the model provided a means to distinguish between novice and expert surgical skills. CONCLUSIONS A plug-and-play lifelike ETV training model was developed through a combination of 3D printing and special effects techniques, providing both anatomical and haptic accuracy. Such simulators offer opportunities to accelerate the development of expertise with respect to new and novel procedures as well as iterate new surgical approaches and innovations, thus allowing novice neurosurgeons to gain valuable experience in surgical techniques without exposing patients to risk of harm.

Thrombopoietin Receptor Agonist Use in Children: Data From the Pediatric ITP Consortium of North America ICON2 Study

BACKGROUND

Data on second-line treatment options for pediatric patients with immune thrombocytopenia (ITP) are limited. Thrombopoietin receptor agonists (TPO-RA) provide a nonimmunosuppressive option for children who require an increased platelet count.

PROCEDURE

We performed a multicenter retrospective study of pediatric ITP patients followed at ITP Consortium of North America (ICON) sites to characterize TPO-RA use.

RESULTS

Seventy-nine children had a total of 87 treatments (28 eltrombopag, 43 romiplostim, and eight trialed on both). The majority had primary ITP (82%) and most (60.8%) had chronic ITP. However, 22% had persistent ITP and 18% had newly diagnosed ITP. During the first 3 months of treatment, 89% achieved a platelet count ≥ 50 × 10(9) /l (86% romiplostim, 81% eltrombopag, P = 0.26) at least once in the absence of rescue therapy. The average time to a response was 6.4 weeks for romiplostim and 7.0 weeks for eltrombopag (P = 0.83). Only 40% of patients demonstrated a stable response with consistent dosing over time. An intermittent response with constant dose titration was seen in 15%, and an initial response that waned to no response was seen in 13%. Significant adverse events were minimal with the exception of two patients with thrombotic events and one who developed a neutralizing antibody.

CONCLUSIONS

Our results demonstrate that TPO-RA agents are being used in children with ITP of varying duration and severity. The response was similar to clinical trials, but the sustainability of response varied. Future studies need to focus on the ideal timing and rationale for these medications in pediatric patients.

Census tract based income level and lipid levels in urban pediatric primary care: a retrospective study

Background

Lower socioeconomic status has been associated with adverse lipid levels in adult populations. Childhood dyslipidemia is a risk factor for future cardiovascular disease. However, studies examining relationships between socioeconomic indicators and lipid levels in children are limited. To examine the relationship between income level and lipid levels in childhood.

Methods

We conducted a retrospective chart review of primary care patients, ages 2 to 18 years, who had lipid levels drawn at two large pediatric practices in Boston, MA between August 01, 2008 and August 31, 2010. Income level was determined using geocoding census tract data. Analysis was performed using t-test, Anova and Spearman correlation coefficients. BMI percentile, age, sex, race/ethnicity, and site were adjusted for on multivariate analyses.

Results

Reviewing 930 charts of patients with measured lipid levels, 730 had a valid address, no previously diagnosed lipid disorder and met other study eligibility criteria. Mean total cholesterol level did not vary by income level (low 155.5 mg/dl ±26.9, moderate 153.5 mg/dl ±30.4, middle 155.3 mg/dl ±26.6 and high income 155.5 mg/dl ±27.9; p = .87) on multivariate analysis. Income level was not related to LDL, HDL, or triglycerides.

Conclusions

In this analysis of children cared for in two urban pediatric primary practices, there was no association between income level determined by census tract and lipid levels in childhood. If confirmed in prospective investigations in other geographical locations, income level may not be a key driver of childhood lipid levels.

Psychiatric disorders and function in adolescents with d-transposition of the great arteries

OBJECTIVE

To compare adolescents with d-transposition of the great arteries (d-TGA) with healthy adolescents with respect to prevalence of psychiatric disorders and global psychosocial functioning.

STUDY DESIGN

Subjects, consisting of 139 adolescents with d-TGA (16.1 ± 0.5 years) and 61 healthy adolescents (15.3 ± 1.1 years) without known risk factors for brain disorders, underwent a battery of assessments, including semistructured psychiatric interviews; self-report measures of depressive, anxiety, and disruptive behavior symptoms; and brain magnetic resonance imaging. Previous cognitive functioning and parental stress assessments at age 8 as well as parental post-traumatic stress at age 16 years were explored as potential risk factors predictive of overall psychiatric functioning.

RESULTS

Compared with healthy adolescents, adolescents with d-TGA had higher lifetime prevalence of structured interview-derived attention-deficit/hyperactivity disorder (19% vs 7%, P = .03), along with reduced global psychosocial functioning (80.6 ± 11.2 vs 87.2 ± 7.1, P < .001) as well as significant increases in self-reported depressive (P = .01), anxiety (P = .02), and disruptive behavior symptoms (parent P < .001 and adolescent P = .03). Nevertheless, these youth scored in the nonclinical range on all self-report measures. Level of global psychosocial functioning was positively related to cognitive functioning (P < .001) and negatively related to parental stress (P = .008).

CONCLUSIONS

Although adolescents with d-TGA demonstrate significant resilience to known neuropsychological and academic deficits, they show increased rates of attention-deficit/hyperactivity disorder and reduced psychosocial functioning. Impaired cognitive functioning and parental stress at younger age emerged as significant risk factors for psychiatric impairment.

Healing patterns of clavicular birth injuries as a guide to fracture dating in cases of possible infant abuse

BACKGROUND

Dating fractures is critical in cases of suspected infant abuse. There are little scientific data to guide radiologists, and dating is generally based on personal experience and conventional wisdom.

OBJECTIVE

Since birth-related clavicular fractures are not immobilized and their age is known, we propose that an assessment of these injuries may serve as a guide for dating inflicted fractures in young infants, acknowledging that patterns observed in the clavicle may not be entirely generalizable to other bones injured in the setting of abuse.

MATERIALS AND METHODS

One hundred thirty-one radiographs of presumed birth-related clavicular fractures in infants between 0 and 3 months of age were reviewed by two pediatric radiologists with 30 and 15 years' experience. Readers were asked to evaluate images based on several parameters of fracture healing, with a focus on subperiosteal new bone formation (SPNBF) and callus formation. SPNBF and callus were each evaluated with regard to presence, thickness and character. Responses were correlated with known fracture ages.

RESULTS

SPNBF was rarely seen in fractures less than 7 days old and was most often present by 10 days. Callus formation was rarely seen in fractures less than 9 days old and was most often present by 15 days. SPNBF thickness increased with fracture age and the character of SPNBF evolved from single-layered to solid/multilayered. Callus thickness decreased with fracture age and callus matrix evolved from soft to intermediate to hard in character.

CONCLUSION

There is an evolution in clavicular fracture healing in young infants that follows a predictable pattern. These findings afford the prospect that predictable patterns of infant clavicular fracture healing can provide an evidence base that may be applicable in cases of suspected infant abuse.

Neuropsychological outcomes of a randomized trial of prednisone versus dexamethasone in acute lymphoblastic leukemia: findings from Dana-Farber Cancer Institute All Consortium Protocol 00-01

BACKGROUND

Dexamethasone is more efficacious than prednisone in the treatment of acute lymphoblastic leukemia (ALL), but has also been associated with greater toxicity. We compared neuropsychological outcomes for patients treated on DFCI ALL Consortium Protocol 00-01, which included a randomized comparison of the two steroid preparations during post-induction therapy in children and adolescents with ALL.

PROCEDURE

Between 2000 and 2005, 408 children with standard-risk or high-risk ALL treated on Dana-Farber Cancer Institute Consortium Protocol 00-01 were randomly assigned to prednisone or dexamethasone administered as 5-day pulses every 3 weeks for 2 years, beginning at week 7 of treatment. Blinded neuropsychological testing was completed for 170 randomized patients (prednisone, N = 76; dexamethasone, N = 94), all of whom were in continuous complete remission after completion of therapy.

RESULTS

Outcomes were comparable for most variables, although patients on the dexamethasone arm performed more poorly on a measure of fluid reasoning (P = 0.02). They also tended to be more likely to be enrolled in special education (dexamethasone, 33% vs. prednisone, 20%, P = 0.09).

CONCLUSIONS

Dexamethasone has well documented benefit in treatment of ALL. Although formal testing provided little indication of increased risk for neurotoxicity relative to prednisone, the somewhat greater utilization of special education services by patients treated with dexamethasone merits further investigation.

Massachusetts emergency departments' resources and physicians' knowledge of management of traumatic dental injuries

BACKGROUND

Hospital emergency departments (ED) are confronted with triaging and managing dental emergencies of both traumatic and non-traumatic origin. However, the literature suggests that there exists inadequate knowledge of the management of traumatic dental injuries (TDI) among medical professionals who must be knowledgeable and have the appropriate resources needed to triage or treat patients presenting with TDI.

AIM

The aims of this study were to (i) evaluate the resources of Massachusetts emergency departments (MEDs) for TDI, (ii) determine the knowledge of management of TDI among MED physicians, and (iii) investigate potential factors that affect their knowledge.

MATERIALS AND METHODS

Surveys were mailed to MED directors and their physicians. The director survey contained questions regarding institutional information for each emergency department (ED). The physician survey contained questions about physician characteristics and tested their knowledge of managing dental trauma.

RESULTS

A total of 72 surveys (16 MED directors and 56 physicians) were returned and included in the analysis. Only 50% of the MEDs had on-site dental coverage, 43.8% had 24-h off-site dental coverage, and none had a formal written dental trauma protocol. MED physician's knowledge of the appropriate management of luxations and avulsions was generally good, but poor for dental fractures. The MED physician's knowledge for the emergent nature of the various injuries was generally good with that of avulsions being the best. Physicians were more likely to have a better knowledge of managing dental trauma if they were specialists in pediatric emergency medicine (P = 0.001) or their hospitals had an academic affiliation (P = 0.05).

CONCLUSIONS

Based on the findings from this study, educational campaigns must be undertaken to improve both the resources available to the ED, and the knowledge of physicians regarding emergency management of TDI. In addition, efforts should be made by local dental organizations to provide ED with lists of dentists who are knowledgeable and willing to be available 24 h day⁻¹ to consult with and, if necessary, treat TDI. These efforts would enhance the long-term outcomes for patients sustaining dental trauma who present to hospital ED.

Home safety practices in an urban low-income population: level of agreement between parental self-report and observed behaviors

Home-related injuries are overrepresented in children from low-income households. The objectives of this study were to determine frequencies of home safety behaviors and the level of agreement between parental self-report and observed safety practices in low-income homes. In a prospective, interventional home injury prevention study of 49 low-income families with children <5 years old, a trained home visitor administered baseline parental home safety behavior questionnaires and assessments. There was high agreement between caregiver self-report and home visitor observation for lack of cabinet latch (99%, 95% confidence interval [CI] = 88%-99%) and stair gate use (100%, 95% CI = 88-100%). There was lower agreement for the safe storage of cleaning supplies (62%, 95% CI = 46%-75%), sharps (74%, 95% CI = 59%-85%), and medicines/vitamins (83%, 95% CI = 69%-92%) because of the overreporting of safe practices. Self-reports of some home safety behaviors are relatively accurate, but certain practices may need to be verified by direct assessment.

Anterior versus posterior approach to iliac crest for alveolar cleft bone grafting

PURPOSE

The goal of this study was to compare perioperative outcomes for the anterior versus posterior approach to the iliac crest for alveolar bone grafting in patients with cleft lip and palate (CLP).

MATERIALS AND METHODS

A retrospective cohort study of patients with CLP who had an anterior or posterior iliac crest bone graft during a 10-year period was performed. Available medical records were reviewed and the outcome variables documented included the operation site for bone graft procurement (anterior or posterior), estimated blood loss, duration of operation, concurrent procedures, and length of hospital stay. The 2 groups were compared by t test, Fisher exact test, and multivariate regression to show differences.

RESULTS

There were 239 patients with CLP who had an iliac crest bone graft to the alveolar cleft; 133 had an anterior and 106 a posterior approach for bone graft procurement. The mean estimated blood loss was significantly less with the posterior approach (85 vs 177 mL; P < .0001). The mean operation duration with the posterior approach was longer (4.6 vs 3.5 hours; P < .0001). Most patients in this group (67%), however, had 2 or more additional procedures during the same anesthetic, whereas only 16% of patients in the anterior group had 2 or more additional procedures. The mean length of stay was significantly shorter for the posterior approach (1.7 vs 2.2 days; P < .0001).

CONCLUSIONS

These results suggest that patients having a bone graft from the posterior iliac crest have a smaller estimated blood loss and a shorter length of stay. In addition, this approach permits repair of the alveolar cleft and additional procedures, including augmentation of the median tubercle and correction of nasolabial distortions, which are often present in patients with CLP.

Family functioning and posttraumatic stress symptoms in youth and their parents after unintentional pediatric injury

This study examined the association between family functioning and the development of posttraumatic stress symptoms (PTSS) in youth and parents following an unintentional traumatic injury of a child. Fifty-one parent-child dyads completed questionnaires and a structured interview assessing PTSS and family functioning. Multiple regression analyses were applied to evaluate the contribution of family functioning to the development of PTSS after controlling for demographic characteristics and known predictors. Family functioning had both direct and moderating influences on the development of PTSS in parents. We were unable to demonstrate a systematic impact of family functioning on the development of PTSS in children from the same families.

Final adult height of children with inflammatory bowel disease is predicted by parental height and patient minimum height Z-score

BACKGROUND

This study was designed to elucidate the contribution of parental height to the stature of children with inflammatory bowel disease (IBD), who often exhibit growth impairment. Accordingly, we compared patients' final adult heights and target heights based on measured parental heights and examined predictors of final adult height in pediatric IBD patients.

METHODS

We prospectively analyzed the growth of 295 patients diagnosed between ages 1 and 18 (211 Crohn's disease [CD], 84 ulcerative colitis [UC]) and their family members (283 mothers, 231 fathers, 55 siblings).

RESULTS

Twenty-two percent had growth impairment (height for age Z-score <-1.64, equivalent to <5th percentile on growth curve) in more than 1 measurement since diagnosis; most growth-impaired patients had CD (88% CD versus 12% UC). Parents of the growth-impaired group had lower mean height Z-scores compared to parents of nongrowth-impaired patients (-0.67 versus 0.02 for mothers [P < 0.001]; -0.31 versus 0.22 for fathers [P = 0.002]). For 108 patients who reached adult heights and had available parental heights, the growth-impaired group continued to demonstrate lower adult height Z-scores (-1.38 versus 0.07; P < 0.001). Adult heights were within 1 SD of target heights even for the growth-impaired group. Only 11.3% remained persistently growth-impaired in adulthood. Multivariate regression analysis demonstrated lower parental height and minimum patient height Z-score as significant predictors of lower final adult height in IBD.

CONCLUSIONS

Parental height is a powerful determinant of linear growth even in the presence of chronic inflammation, and should be an integral part of the evaluation of growth in IBD children.

Impact of a patient-centered technology on medication errors during pediatric emergency care

OBJECTIVE

The aim of this study was to determine the impact of a patient-centered health information technology (HIT) on the error rate for ordering and prescribing of medications during emergency pediatric care.

METHODS

We conducted a quasi-experimental intervention study by using control and intervention periods to evaluate the effect on medication ordering and prescribing from a patient-centered HIT designed to enhance communication between parents and emergency clinicians during emergency care. Parent-child dyads presenting to 2 emergency department (ED) sites with complaints of fever, asthma, head trauma, otalgia, and dysuria were eligible. During intervention periods, parents used the HIT to enter data on symptoms and medication-related history; a printout provided recommendations to clinicians. Data on errors/adverse drug events were collected via record reviews and phone interviews with parents. The primary outcome was the number of medication errors in orders or prescriptions for drugs targeted by the HIT.

RESULTS

Of 2002 parent-child dyads screened, 1810 (90%) were eligible, 1411 of 1810 (78%) were enrolled, and 1410 analyzed; 1097 subjects had a total of 2234 orders or prescriptions written. Of these events, 1289 of 2234 (58%) were associated with at least 1 error. Of the 1755 errors discovered, 232 errors were serious and preventable. Among 654 patients exposed to medications targeted by the HIT, the number of errors per 100 patients during control versus intervention periods was not significantly different (173 vs 134 with both sites combined; P = .35.)

CONCLUSION

The patient-centered HIT demonstrated minimal impact on medication errors during ED care.

The NIH MRI study of normal brain development: performance of a population based sample of healthy children aged 6 to 18 years on a neuropsychological battery

The National Institutes of Health (NIH) Magnetic Resonance Imaging (MRI) Study of Normal Brain Development is a landmark study in which structural and metabolic brain development and behavior are followed longitudinally from birth to young adulthood in a population-based sample of healthy children. The neuropsychological assessment protocol for children aged 6 to 18 years is described and normative data are presented for participants in that age range (N = 385). For many measures, raw score performance improved steeply from 6 to 10 years, decelerating during adolescence. Sex differences were documented for Block Design (male advantage), CVLT, Pegboard and Coding (female advantage). Household income predicted IQ and achievement, as well as externalizing problems and social competence, but not the other cognitive or behavioral measures. Performance of this healthy sample was generally better than published norms. This linked imaging-clinical/behavioral database will be an invaluable public resource for researchers for many years to come.

Hospital volumes for common pediatric specialty operations

OBJECTIVES

To describe hospital volumes for common pediatric specialty operations, to evaluate hospital and patient characteristics associated with operations performed at a low-volume hospital, and to evaluate outcomes with hospital volume.

DESIGN

Retrospective cohort using the Kids' Inpatient Database 2003.

SETTING

Discharges from 3438 hospitals in 36 states from 2003.

PARTICIPANTS

Children aged 0 to 18 years undergoing ventriculoseptal defect surgery (n = 2301), tracheotomy (n = 2674), ventriculoperitoneal shunt placement (n = 3378), and posterior spinal fusion (n = 4002).

MAIN EXPOSURE

Hospital volume.

MAIN OUTCOME MEASURES

In-hospital mortality and postoperative complications.

RESULTS

For tracheotomy and posterior spinal fusion, at least one fourth of the hospitals performed only 1 operation for children aged 0 to 18 years in 2003. For these same operations, at least half of hospitals treated 4 or fewer cases per year. For all operations, discharges from low-volume hospitals were less likely to be from children's or teaching hospitals compared with discharges from higher-volume hospitals. For tracheotomy, children were less likely to experience postoperative complications in high-volume hospitals compared with low-volume hospitals (odds ratio, 0.48; 95% confidence interval, 0.21-1.09).

CONCLUSIONS

Many children undergoing common pediatric specialty operations had these procedures performed in low-volume hospitals. Low-volume hospitals were less likely to be children's or teaching hospitals. Children undergoing tracheotomy experienced higher rates of complications in low-volume hospitals. Further research is needed to identify the reasons why so many children have these operations performed in low-volume hospitals.

Incorporating vaccine-preventable disease surveillance into the National Health Information Network: leveraging children's hospitals

OBJECTIVE

Development of national biosurveillance systems to advance regional and national data exchange among sites of clinical care and public health authorities is a top federal priority, creating the opportunity to develop a unified national network for tracking and responding to cases of vaccine-preventable diseases. The purpose of this study was to assess the current practice and feasibility of developing a nationwide network of children's hospitals to conduct surveillance for vaccine preventable diseases.

METHODS

In 2004-2005, Web-based surveys were sent to 506 key hospital personnel from 119 pediatric hospitals, identified by the National Association of Children's Hospitals and Related Institutions. Surveys measured attitudes toward public health initiatives, willingness to join a surveillance network of children's hospitals, knowledge of mandated reporting requirements, methods of disease detection and reporting, and data sources available for surveillance.

RESULTS

A total of 395 (78%) respondents from 119 hospitals completed the survey. Surveillance at pediatric hospitals is largely passive and driven by unreimbursed efforts of infection control staff. It is vulnerable to missing cases that occur in the outpatient setting and are diagnosed clinically without laboratory confirmation or are never diagnosed by clinicians. Nearly 90% of hospital leaders are interested in participating in public health programs, and most are interested in a national network to conduct active surveillance for vaccine-preventable diseases, dependent on the provision of sufficient funding. Pediatric hospitals store records relevant to surveillance in an electronic fashion accessible to query, but <20% of these hospitals use automated methods to report cases of disease.

CONCLUSIONS

There is both the will and capability to create a robust active pediatric hospital-based reporting system for vaccine preventable diseases. This effort would dovetail well with the national priority to bolster surveillance, as well as with the goal of reducing morbidity and mortality from vaccine-preventable diseases.

Variation in the Management of Pediatric Splenic Injuries in the United States

BACKGROUND

This study examines the existence and sources of variation in the management of pediatric splenic injuries among hospitals in the United States and the factors associated with splenectomy.

METHODS

Information on children 15 years of age and younger with a splenic injury diagnosis code was extracted from the Kids' Inpatient Database 2000, a pediatric inpatient database of 2,784 hospitals in 27 states covering 72% of the nation's population for the year 2000. Patient variables included age, sex, race, injury diagnoses, grade of splenic injury, splenic procedure code, and calculated Injury Severity Score. Hospital variables included pediatric status (free-standing, unit and adult), teaching status, annual pediatric splenic trauma volume, and national region. A multivariate logistic regression model was used to predict the factors associated with splenectomy based upon patient and hospital characteristics.

RESULTS

In all, 2,191 children with splenic injuries were identified; 253 (12%) underwent splenectomy. The crude rate of splenectomy varied significantly among pediatric hospital types: 3% (11/339) at freestanding children's hospitals, 9% (45/525) at unit hospitals and 15% (197/1327) at adult hospitals (p < 0.001). Risk of splenectomy increased with the grade of splenic injury, patient age, and the presence of multiple injuries. Teaching hospitals and hospitals with higher patient volume were associated with lower risk for splenectomy. There was no relationship between splenectomy and gender, race, or national region. Despite adjustment for the above noted hospital and patient-specific variables, children treated at an adult hospital had 2.8 times the odds, and those treated at a unit pediatric hospital 2.6 times the odds, of undergoing splenectomy as those cared for at a free-standing pediatric hospital (p = 0.003 and 0.013, respectively).

CONCLUSION

Nationally, children cared for at freestanding pediatric hospitals have a significantly lower risk of splenectomy than children treated at either adult hospitals or pediatric hospitals within an adult hospital. This may have implications for education, trauma triage and the establishment of practice guidelines.

Executive Functions and Performance on High-Stakes Testing in Children From Urban Schools

High-stakes achievement testing is a centerpiece of education reform. Children from socially disadvantaged backgrounds typically perform more poorly than their more advantaged peers. The authors evaluated 91 fifth-grade children from low-income urban schools using clinical neuropsychological tests and behavioral questionnaires and obtained fourth-grade scores on state mandated standards-based testing. Goals were to determine whether executive functions are selectively diminished in children from poor urban environments and to evaluate to what extent integrity of executive functions is associated with test scores. Neuropsychological variables (particularly executive functions) accounted for 40% of the variance in English scores and 30% in mathematics. Efforts to improve children's academic achievement should consider developmental factors as well as curricular content.

Cumulative fluid intake minus output is not associated with ventilator weaning duration or extubation outcomes in children

OBJECTIVE

The effect of fluid balance on respiratory outcomes for critically ill children has not been evaluated. The only indicator of fluid balance routinely recorded across our intensive care units was estimated fluid intake and output. We sought to determine whether cumulative intake minus output (I-O) at the start of weaning predicted weaning duration and whether cumulative I-O at extubation predicted extubation failure.

DESIGN

Prospective observational study.

SETTING

Ten pediatric intensive care units.

PATIENTS

Cumulative I-O was recorded daily for 301 mechanically ventilated children (<18 yrs of age) from November 1999 through April 2001.

INTERVENTIONS

Cumulative I-O was recorded during a study of weaning strategies and extubation failure in which mechanical ventilation of the majority of patients during weaning and extubation was managed according to a protocol that did not include fluid balance indicators. Outcomes were the time to successful removal of ventilatory support and the rate of initial extubation failure.

MEASUREMENTS AND MAIN RESULTS

Relationships between cumulative I-O and outcomes were assessed by means of proportional hazards and logistic regression. The mean cumulative I-O per kilogram of ideal body weight at the start of weaning was 101 mL (sd, 180). Cumulative I-O at the time weaning was initiated did not predict duration of mechanical ventilator weaning. The mean cumulative I-O per kilogram of ideal body weight at extubation was 136 mL (sd, 237). Cumulative I-O at extubation did not predict extubation outcome. There was an association between cumulative I-O at extubation and the duration of weaning in cases not managed by a protocol.

CONCLUSION

Although routinely recorded, cumulative fluid I-O does not appear to have clinical utility in cases managed according to a mechanical ventilator protocol in which tidal volume and oxygenation on minimal levels of ventilator support are systematically tested.

Physiology after Pediatric Splenic Injury

BACKGROUND

The splenic injury computed tomographic (CT) grade is used to guide nonoperative management. A study was conducted to determine whether this grade correlates with patient physiology.

METHODS

Records of consecutive children with isolated spleen injuries were reviewed. Vital signs, fluids administered, urine output, and hematocrit values from the scene through 120 hours after admission were retrieved. A blinded radiologist reviewed CT scans. Statistical analyses were conducted to test for a linear relationship between injury grade and physiologic parameters.

RESULTS

Eighty-two patients with isolated splenic injuries and available CT scans were located. CT injury grade correlated directly with pulse, systolic blood pressure, and diastolic blood pressure and inversely with hematocrit. No correlation was found with pulse pressure, urine output, or maximum temperature.

CONCLUSION

The CT grade of splenic injury correlates directly with pulse, systolic blood pressure, and diastolic blood pressure and inversely with hematocrit. CT injury grade correlates with physiologic impact and may guide management decisions.

Neurodevelopmental characteristics of children with learning impairments classified according to the double-deficit hypothesis

The double-deficit model has been examined primarily in relation to reading. We investigated whether children classified according to the double-deficit model would exhibit differences in other neuropsychological domains. Children referred for learning problems (N = 188), ages 7 to 11, were classified by double-deficit subtype. Only three of the four groups predicted by the model could be identified. There were no group differences in IQ or attention problems. The three groups showed different neuropsychological profiles, involving functional domains other than reading and language. Differences also emerged in nonverbal low-level information processing. The double-deficit group was generally most severely affected. The double-deficit groupings identify children with different neuropsychological profiles and variation in the efficiency of basic online information processing, extending beyond the oral and written language domain.

Variation in the Management of Pediatric Splenic Injuries in New England

BACKGROUND

Nonoperative management of stable children with splenic injuries is the standard of care but has been variably applied in New England. The influence of surgeon training on this variation was analyzed.

METHODS

A region-wide administrative data set was queried for children with a splenic injury from 1990 through 1998. The influence of a range of patient- and hospital-specific variables, including surgeon pediatric training, on the risk of operation was analyzed.

RESULTS

The risk of operation increased with age, severity of splenic injury, and the presence of multiple injuries, but also trauma center status and the presence of a surgical training program. After allowance for these variables, the risk of operation was reduced by half when children with splenic injuries were cared for by a surgeon with pediatric specialty training.

CONCLUSION

The risk of operation for pediatric splenic injury in New England is dependent on several variables, including the surgeon's training.

Neurobehavioral factors associated with referral for learning problems in a community sample: evidence for an adaptational model for learning disorders

We evaluated community general education (CGE; n = 178), community special education (CSE; n = 30) and hospital-referred (HR, n = 145) children (ages 7-6 to 11-11) prospectively over a 2-year period. During this period, 17 CGE children were referred for evaluation (community referred; CR). Prior to referral, CR children performed more poorly than community-nonreferred (CNR) children on cognitive ability, academic achievement, attention problems, and information processing. CR group performance was equivalent to that of CSE and HR groups, but HR children showed poorer academic achievement. Referred children performed more poorly on all measures than nonreferred, whether they met formal diagnostic criteria for a learning disorder or not. Learning disorders may be better conceptualized as a context-dependent problem of functional adaptation than as a disability analogous to physical disabilities, raising questions about the validity of using psychometric test scores as the criterion for identification.

The feasibility of conducting clinical trials in infants and children with acute respiratory failure

Designing robust clinical trials in critically ill, mechanically ventilated children requires an understanding of the epidemiology and course of pediatric respiratory failure. As part of a clinical trial, we screened all mechanically ventilated children in nine large pediatric intensive care units (ICUs) across North America for 6 consecutive months. Of 6,403 total ICU admissions, 1,096 (17.1%) required mechanical ventilator support for a minimum of 24 hours. Of these, 701 (64%) met one or more exclusion criteria for trial enrollment. Common reasons for exclusion were upper airway obstruction (13.5%) and cyanotic congenital heart disease (11.5%). Life support interventions were restricted for 9.7% of patients, and 5.5% were chronically ventilator dependent. In the patients who were eligible for respiratory failure studies, 62.4% had an acute primary diagnosis of pulmonary disease, 14.2% neurologic disease, and 8.9% cardiac disease. Chronic underlying conditions were present in 43.2% of the patients. The most common acute diagnosis was bronchiolitis in infants (43.6%) and pneumonia in children 1 year old and older (24.5%). Mortality was rare (1.6%), and the median duration of ventilation was 7 days. The design of clinical trials in critically ill children is feasible but must account for the diverse population, infrequent mortality, and short duration of mechanical ventilation.

Motor sequence learning and reading ability: is poor reading associated with sequencing deficits?

Although it is widely assumed that children with learning disabilities have "sequencing problems," these have not been well specified. A non-verbal serial reaction time (SRT) paradigm was used to evaluate motor sequence learning in 422 children between ages 7 and 11 in relation to reading, cognitive ability level, and attention problems. The children demonstrated the response profile typically associated with motor sequence learning, but the component of the profile indicative of implicit sequence learning was not reliably associated with any of the predictors. Cognitive ability predicted overall response time; cognitive ability, reading, and attention problems each predicted overall accuracy. Explicit learning was predicted by cognitive ability, but not by reading or attention problems. Thus, we found no evidence that poor reading is preferentially associated with a domain general deficit in sequential learning.

A functional magnetic resonance imaging study of paced finger tapping in children

Fourteen typically developing children from 7.9-11.3 years in age were studied with functional magnetic resonance imaging to identify the cerebral loci involved in performance of paced finger tapping by children. Each child performed two bimanual alternating paced finger-tapping tasks. In the first, paced finger tapping was conducted to external 3-Hz pacing provided by a metronome. In the second, the metronome was turned off and finger tapping continued while each child tried to maintain the 3-Hz rhythm by self pacing. Individual and group data were analyzed with statistical parametric mapping techniques that resulted in activation maps for the two tasks. Metronome tapping produced activation of the posterior regions of both superior temporal gyri, both primary sensorimotor cortices, anterodorsomedial cerebellum and supplementary motor area. Self-tapping resulted in recruitment of pre-supplementary motor area and cerebellum in addition to bilateral supplementary motor area and primary sensorimotor cortical activation. Bimanual alternating paced finger tapping performed by children activates a neural network involving primary motor cortex, supplementary motor area, and cerebellum. Posterior superior temporal gyrus may be important for encoding auditory information, and presupplementary motor area and midline cerebellum play an important role in self-paced finger tapping.

Sources of poor performance on the Rey-Osterrieth Complex Figure Test among children with learning difficulties: a dynamic assessment approach

A dynamic assessment approach was used to examine the source of poor performance on the Rey-Osterrieth Complex Figure Test (ROCF) among 202 school-age children referred for learning difficulties. The ROCF was administered in the standard format and then in a structured format that highlighted the design's organizational framework. Manipulating encoding in this way improved recall to at least age-level for the majority of children. Those children who did not benefit from the structured format had relatively poor visual organizational skills. For most children with learning problems, poor ROCF performance stems from metacognitive difficulties; for a minority, the source appears to be more perceptual. A dynamic assessment procedure can enhance the diagnostic utility of the ROCF for children.

Diminished motor timing control in children referred for diagnosis of learning problems

Disabled readers exhibit motor timing control (MTC) deficits in bimanual coordination relative to average readers. This article evaluates to what extent poor MTC is specific to reading or if it is related to learning problems in general. Children (7 to 11 years of age) referred for learning impairment (LI; n = 100) and same-age children nonlearning impaired (NLI; n = 243) performed a paced finger-tapping task. Greater variability of interresponse intervals was associated with poorer reading, spelling, and arithmetic achievement. The LI group performed more poorly than the NLI group, a difference that persisted even after adjusting for reading skill. Poor MTC is associated with poor reading but may also be a characteristic of children referred for learning problems, possibly signaling increased vulnerability of underlying neural integrative processes relevant to the child's adaptation to academic demands, including reading.

Rapid automatized naming in children referred for evaluation of heterogeneous learning problems: how specific are naming speed deficits to reading disability?

Because the Rapid Automatized Naming (RAN) test reliably predicts reading skill, it is typically viewed as a diagnostic indicator of risk for reading disability (RD). Since most of the work on naming speed has been undertaken within the framework of reading research, however, the extent to which poor RAN is specifically associated with RD or with learning impairment (LI) in general is uncertain. We tested the hypothesis that slow naming speed is specific to RD. Participants were 188 children (ages 7 to 11) referred for evaluation of learning problems. Receiver operating characteristic (ROC) analysis was used to evaluate the utility of the RAN task for classifying children in diagnostic groups. RAN was an excellent tool for detecting risk for learning problems in general, but it was much less effective at distinguishing LI children with and without RD from each other.