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Abstracts of Staff Publications aFall 2000 Asthma medications and how to use them Jacqueline A. Pongracic
Aerosolized medications for the treatment of asthma are now considered to be the delivery system of choice. Despite their popularity, traditional pressurized metered dose inhalers are associated with a variety of drawbacks. This article reviews the aerosolized drug delivery systems currently available, along with their advantages and disadvantages. Patient technique in the use of these agents is addressed. Special considerations in children and the elderly are discussed, with specific recommendations tailored to these age groups, followed by practical suggestions for general inhaler use. Preoperative preparation and premedication Charles Coté
Preparing the paediatric patient for their operating room experience can be a complex process because of the many individuals involved. Preparation begins before patients have seen an anaesthetist because they will learn of their impending surgery from the surgeon. Surgical colleagues and their support staff can help to ease patients’ anxieties by assuring them that their child will receive the best anesthetic care possible. The anesthetist may first meet the child in a preoperative screening clinic a week or two before the scheduled surgery or on the morning of the procedure. Increasingly, in countries trying to reduce health care costs there may be only a few minutes to interview and evaluate the family and child. The use of preoperative hospital tours, educational videos and pamphlets have been demonstrated to have value in reducing patient and parent anxiety. Educational tours appear to have particular value for children older than 6 yrs. Parents of children less than 1 yr of age and those undergoing surgery for the first time are particularly anxious. In the USA, approximately 80% of paediatric surgical procedures are performed on an outpatient basis or on a ‘same day admission’ basis. Although cost effective, this shortened process limits the time that the anaesthetist has to evaluate the child. Screening clinics help in arranging evaluation of underlying medical conditions (seizure disorders, asthma, diabetes, severe cardiac, pulmonary, renal, hepatic, neurological, metabolic or haematopoietic problems). Preoperative phone calls are of great value in helping to ascertain if the child is suffering from an acute upper respiratory tract infection (URTI) which might warrant postponing an elective procedure. Effectiveness of the angiogenesis inhibitor TNP-470 in reducing the growth of human neuroblastoma in nude mice inversely correlates with tumor burden Howard Katzenstein, Alfred Rademaker, Christof Senger, Helen Salwen, Nadine Nguyen, Paul Thorner, Louis Litsas, and Susan Cohn
Angiogenesis plays an important role in the growth and metastasis of malignant tumors. We have previously reported that in children with neuroblastoma (NB), tumor vascularity directly correlates with metastatic disease, MYCN amplification, and poor outcome. The angiogenesis inhibitor TNP-470 has been shown to reduce the rate of NB growth in rodents with macroscopic tumors without ultimately impacting survival. To investigate whether TNP-470 could more effectively inhibit NB growth in animals with a low tumor burden, we treated 30 nude mice with minimal disease with this angiogenesis inhibitor (supplied by TAP Pharmaceuticals, Inc.). Therapy was initiated before tumors were clinically evident after s.c. inoculation of 5 x 106 cells from the MYCN-amplified NB cell line NBL-W-N. TNP-470 was administered 3days/week, and after 12 weeks of treatment, 53% of the treated mice remained tumor free, whereas 100% of the control mice developed tumors (P<0.0001). To further assess the relationship between the efficacy of TNP-470 treatment and tumor burden, TNP-470 was also administered s.c., 3 days/week, to mice with clinically evident small (<400 mm3; n=15) and large (>400 mm3; n=11) tumors. For animals with small tumors, the mean rate of growth was significantly decreased in the treated mice compare to the controls (P=0.02). In contrast, there was no difference in the mean rate of tumor growth between animals with large tumors treated with TNP-470 and controls (P=0.64). Our studies demonstrate the effectiveness of TNP-470 may most effectively inhibit NB tumor growth inn children with a low tumor burden. Neutral tube defects and the 13q deletion syndrome: Evidence for a critical region in 13q33-34s Jeffrey Luo, Nancy Balkin, Julie F. Stewart, John F. Sarwark, Joel Charrow, and Jeffrey S. Nyer
Neural tube defects (NTD) are common findings in the 13q deletion syndrome, but the relationship between the 13q- syndrome and NTDs is poorly understood. We present a child with a 13q deletion and lumbosacral myelomeningocele. This was a boy with microcephaly, telecanthus, minor facial anomalies, and ambiguous genitalia. Cytogenetic and fluorescence in situ hybridization analysis showed a de novo 46,XYdel(13)(q33.2®qter) with no visible translocation. By using microsatellite markers, the deletion breakpoint was mapped to a 350-kb region between D13S274 and D13S1311 and was paternal in origin. An analysis of 13q deletions with NTDs, including the present case, suggests that a deletion in 13q33-34 is sufficient to cause an NTD. The deletions associated with NTDs are distal to and nonoverlapping with the previously defined critical region in 13q32 for the major malformation syndrome [Brown et al., 1999: Am J Hum Genet 57: 859–866]. Our analysis also suggests that one or more genes in 13q33-34 produces NTDs by haploinsufficiency. Histopathology of congenital subglottic stenosis Lauren Holinger
A precise delineation of each laryngeal abnormality is critical to planning rational therapy. Since congenital cricoid cartilage anomalies are easily overlooked, a systematic approach to their identification is as important as a clear concept of their classification. The purpose of this communication is to present the pathologic findings and classification of congenital cricoid cartilage deformities and to summarize updated information derived by the whole organ macrosection technique. The classification of congenital subglottic stenosis is based on study of the English-language literature and the collection in the Laryngeal Development Laboratory at Children’s Memorial Hospital in Chicago. Twenty-nine specimens with congenital cricoid abnormalities have been identified. Fourteen have an elliptical cricoid cartilage; 12, laryngeal cleft; 5, a flattened shape; 1, a large anterior lamina; and 3, generalized thickening. Some specimens have more than 1 anomaly. Eight cases of fragmented or distorted cricoid cartilages are thought to be acquired lesions. An anterior submucous cricoid cleft has been identified and is presented for the first time. Language barriers and resource utilization in a pediatric emergency department Louis Hampers, Susie Cha, David Gutglass; Helen Binns, Steven Krug
Background: Although an inability to speak English is recognized as an obstacle to health care in the United States, it is unclear how clinicians alter their diagnostic approach when confronted with a language barrier (LB). Objective: To determine if a LB between families and their emergency department (ED) physician was associated with a difference in diagnostic testing and length of stay in the ED. Design: Prospective cohort study. Methods: This study prospectively assessed clinical status and care provided to patients who presented to a pediatric ED from September 1997 through December 1997. Patients included were 2 months to 10 years of age, not chronically, ill, and had a presenting temperature $38.5ºC or complained of vomiting, diarrhea, or decreased oral intake. Examining physicians determined study eligibility and recorded the Yale Observation Score if the patient was 3 years old, and whether there was a LB between the physician and the family. Standard hospital charges were applied for each visit to any of the 22 commonly ordered tests. Comparisons of total charges were made among groups using Mann-Whitney U tests. Analysis of covariance was used to evaluate predictors of total charges and length of ED stay. Results: Data were obtained for about 2467 patients. A total of 286 families (12%) did not speak English, resulting in a LB for the physician in 209 cases (8.5%). LB patients were much more likely to be Hispanic (88% vs 49%), and less likely to be commercially insured (19% vs 30%). These patients were slightly younger (mean 31 months vs 36 months), but had similar acuity, triage vital signs, and Yale Observation Score (when applicable). In cases in which a LB existed, mean test charges were significantly higher: $145 versus $104, and ED stays were significantly longer: 165 minutes versus 137 minutes. In an analysis of covariance model including race/ethnicity, insurance status, physician training level, attending physician, urgent care setting, triage category, age, and vital signs, the presence of a LB accounted for a $38 increase in charges for testing and a 20 minute longer ED stay. Conclusion: Despite controlling for multiple factors, the presence of a physician-family LB was associated with a higher rate of resource utilization for diagnostic studies and increased ED visit times. Additional study is recommended to explore the reason for these differences and ways to provide care more efficiently to non-English-speaking patients. Injury prevention education using pictorial information Elizabeth Powell, Robert Tanz, Andrew Uyeda, Mary Beth Gaffney, Karen Sheehan
URL: http://www.pediatrics.org/cgi/content/full/105/1/e16 Background: Written materials used in pediatric public health settings often exceed the reading skills of caretakers. Objective: To compare a pictorial anticipatory guidance (PAG) sheet requiring limited reading skills to a TIPP (The Injury Prevention Program) sheet for providing injury prevention information to low-income urban families. Design and Setting: A convenience sample of families with children treated at an urban pediatric clinic affiliated with a teaching hospital. Methods: Parents of children #6 years old received either a PAG sheet or a TIPP sheet during a well-child care clinic visit; parents of children seen in the morning clinic received a PAG sheet and those seen during the afternoon clinic a TIPP sheet. All also received injury prevention counseling by a clinic nurse. The recall of injury prevention information was assessed by telephone questionnaire 14 to 28 days after the clinic encounter. Results: We interviewed 66 parents (57% of families enrolled): 46 were in the PAG group and 20 in the TIPP group. There were no differences between groups in mean parent age, percent minority race, or percent public aid. Eighty-seven percent of PAG and 100% of TIPP parents recalled receiving an information sheet; 17% of PAG and 20% of TIPP parents could recall no specific injury topics. The mean number of topics recalled was 2.1±1.5 from parents in the PAG group and 1.6±1.1 from those in the TIPP group. No specific injury topic was recalled by more than half the parents in either group. Conclusion: Conclusion: Recall of injury information several weeks after a clinic visit is limited. The use of PAG sheets did not improve recall; lack of literacy is not the sole cause of poor recall. Successful injury prevention counseling in this population may require comprehensive and repetitive efforts. Dexamethasone reduces the inflammatory response to cardiopulmonary bypass in children Ronald Bronicki, Carl Backer, Harris Baden, Constantine Mavroudis, Susan Crawford, Thomas Green
Background: A randomized prospective, double-blind study of 29 children was performed to evaluate the hypothesis that dexamethasone administration prior to cardiopulmonary bypass would decrease the inflammatory mediator release and improve the postoperative clinical course. Methods: Fifteen children received dexamethasone (l mg/kg intravenously) and 14 (controls) received saline solution 1 hours prior to CPB. Serial blood analysis for interleukin-6, tumor necrosis factor-a, complement component C3a, and absolute neutrophil count were performed. Postoperative variables evaluated included temperature, supplemental fluids, alveolar-arterial oxygen gradient, and days of mechanical ventilation. Results: Dexamethasone caused an eightfold decrease in interleukin-6 levels and a greater than threefold decrease in tumor necrosis factor-a levels after CBP (p<0.05). Complement component C3a and absolute neutrophil count were not affected by dexamethasone. The mean rectal temperature for the first 24 hours postoperatively was significantly lower in the group given dexamethasone than in the controls (37.2º±0.4°C versus 37.7°±4°C; p=0.007) Dexamethasone-treated patients required less supplemental fluid during the first 48 hours (22±28 mL/kg versus 47±34 mL/kg; p=0.04). Compared with controls, dexamethasone-treated children had significantly lower alveolar-arterial oxygen gradients during the first 24 hours (144±108 mm Hg versus 214±118 mm Hg; p=0.02) and required less mechanical ventilation (median duration, 3 days versus 5 days; p=0.02). Conclusions: Dexamethasone administration prior to CPB in children leads to a reduction in the postbypass inflammatory response as assessed by cytokine levels and clinical course. Prevalence of symptoms of gastroesophageal reflux during childhood: A pediatric practice-based survey Suzanne Nelson, Edwin Chen, Gina Syniar, Katherine Kaufer Christoffel, for the Pediatric Practice Research Group
Objectives: To determine the prevalence of symptoms associated with gastroesophageal reflux (GER) in 3- to 17-year old children, to describe the prevalence of factors associated with GER in these children, and to determine the percentage of symptomatic children who have been treated. Design: A cross-sectional survey. Setting: Sixteen pediatric practice research group practices in the Chicago, III, area (urban, suburban, and semirural). Participants: A total of 566 parents of 3- to 9-year-old children, 584 parents of 10- to 17- year-old children, and 615 children aged 10 to 17 years.. Intervention: None. Main Outcome Measure: Reported frequency of symptoms associated with GER. Results: Parents 3- to 9-year-old children reported that their children experienced a sensation of heartburn (“burning/painful feeling in middle of chest”), epigastric pain (“stomachache above belly button”), and regurgitation (“sour taste or taste of throw up”) 1.8%, 7.2%, and 2.3% of the time, respectively. Parents of 10- to 17-year-old children reported that their children experienced the same symptoms 3.5%, 3.0%, and 1.4% of the time, while children aged 10 to 17 years reported the symptoms 5.2%, 5.0%, and 8.2% of the time, respectively. Complaints of abdominal pain (“stomachache”) were most common, reported by 23.9% and 14.7% parents of 3-to 9-year-old and 10- to 17-year-old children and by 27.9% of children aged 10 to 17 years. In those aged 10 to 17 years, heartburn reported by the children was associated with reported cigarette use (odds ratio, 6.5; 95% confidence interval, 2–21); no other compliant was associated with cigarette, alcohol, or caffeine consumption or passive smoking exposure. In 3- to 9-year-old children, no complaint was associated with caffeine consumption or passive smoking exposure. Reported treatment in the past week with antacids was 0.5% according to parents of children aged 3 to 9 years and 1.9% and 2.3% according to parents of children aged 10 to 17 years and children aged 10 to 17 years, respectively. Treatment with over-the-counter histamine receptor blockers was 0% for children aged 3 to 9 years and 10 to 17 years, as reported by their parents, and 1.3% for those aged 10 to 17 years, as reported by themselves. Conclusions: Symptoms suggestive of GER are not rare in childhood, yet only a fraction of children with symptoms are treated with over-the-counter antacids or histamine antagonists. Prospective longitudinal data are needed to determine which children with symptoms of GER actually have GER disease and are at risk of developing complications. |