Archives of pediatrics & adolescent medicine最新文献

Objective: To develop a brief screening instrument to assess the risk for suicide in pediatric emergency department patients.

Design: A prospective, cross-sectional instrument-development study evaluated 17 candidate screening questions assessing suicide risk in young patients. The Suicidal Ideation Questionnaire served as the criterion standard.

Setting: Three urban, pediatric emergency departments associated with tertiary care teaching hospitals.

Participants: A convenience sample of 524 patients aged 10 to 21 years who presented with either medical/surgical or psychiatric chief concerns to the emergency department between September 10, 2008, and January 5, 2011.

Main exposures: Participants answered 17 candidate questions followed by the Suicidal Ideation Questionnaire.

Main outcome measures: Sensitivity, specificity, predictive values, likelihood ratios, and area under the receiver operating characteristic curves of the best-fitting combinations of screening questions for detecting elevated risk for suicide.

Results: A total of 524 patients were screened (344 medical/surgical and 180 psychiatric). Fourteen of the medical/surgical patients (4%) and 84 of the psychiatric patients (47%) were at elevated suicide risk on the Suicidal Ideation Questionnaire. Of the 17 candidate questions, the best-fitting model comprised 4 questions assessing current thoughts of being better off dead, current wish to die, current suicidal ideation, and past suicide attempt. This model had a sensitivity of 96.9% (95% CI, 91.3-99.4), specificity of 87.6% (95% CI, 84.0-90.5), and negative predictive values of 99.7% (95% CI, 98.2-99.9) for medical/surgical patients and 96.9% (95% CI, 89.3-99.6) for psychiatric patients.

Conclusions: A 4-question screening instrument, the Ask Suicide-Screening Questions (ASQ), with high sensitivity and negative predictive value, can identify the risk for suicide in patients presenting to pediatric emergency departments.

Objectives: To investigate whether the degree of obesity predicts the efficacy of long-term behavioral treatment and to explore any interaction with age.

Design: A 3-year longitudinal observational study. Obese children were divided into 3 age groups (6-9, 10-13, and 14-16 years) and also into 2 groups (moderately obese, with a body mass index [BMI]-standard deviation [SD] score [or z score] of 1.6 to <3.5, and severely obese, with a BMI-SD score of ≥3.5).

Setting: National Childhood Obesity Center, Stockholm, Sweden.

Participants: Children 6 to 16 years of age who started treatment between 1998 and 2006.

Intervention: Behavioral treatment of obesity.

Main outcome measure: Change in BMI-SD score during 3 years of treatment; a reduction in BMI-SD score of 0.5 units or more was defined as clinically significant.

Results: A total of 643 children (49% female children) met the inclusion criteria. Among the youngest moderately obese children, 44% had a clinically significant reduction in BMI-SD score (mean reduction, -0.4 [95% CI, -0.55 to -0.32]). Treatment was less effective for the older moderately obese children. Twenty percent of children who were 10 to 13 years of age and 8% of children who were 14 to 16 years of age had a reduction in BMI-SD score of 0.5 units or more; 58% of the severely obese young children showed a clinically significant reduction in BMI-SD score (mean reduction, -0.7 [95% CI, -0.80 to -0.54]). The severely obese adolescents showed no change in mean BMI-SD score after 3 years, and 2% experienced clinically significant weight loss. Age was found to be a predictor of a reduction in BMI-SD score (odds ratio, 0.68 units per year [95% CI, 0.60-0.77 units per year]).

Conclusions: Behavioral treatment was successful for severely obese children but had almost no effect on severely obese adolescents.

Objectives: To assess the occurrence of sleep-disordered breathing, hypoxemia, and sleep architecture in a cohort of infants and children with cystic fibrosis (CF) and normal or mildly impaired lung function in stable clinical condition.

Design: Case-control study.

Setting: Cystic Fibrosis Unit of a university hospital and pediatric sleep laboratory.

Participants: A total of 40 children (aged 6 months to 11 years) with CF in stable condition and 18 healthy age-matched control subjects.

Intervention: Nocturnal sleep and cardiorespiratory monitoring was performed using a full polysomnographic recording in a sleep laboratory.

Main outcomes measures: Sleep architecture and respiratory variables.

Results: Although awake oxyhemoglobin saturation (SaO2) values were similar in the 2 groups (98%), the CF group had significantly lower values of nocturnal mean SaO2. The apnea-hypopnea index was significantly higher in the CF group compared with the controls (mean [SE], 7.3 [1.3] vs 0.5 [0.4], respectively, P < .001), particularly in preschool-aged children and in children with upper airway abnormalities. In addition, 28 (70%) of the 40 children with CF had mild to moderate obstructive sleep apnea (defined as an apnea-hypopnea index >2). Children with CF compared with controls also had reduced sleep efficiency (CF group vs controls mean [SE], 80% [41%] vs 88% [13.1%], P < .001), rapid eye movement sleep duration (11% [0.9%] vs 13% [1%], P < .05), and increased number of arousals per hour (11.0 [10] vs 8.2 [0.7], P < .001).

Conclusions: This study showed an early occurrence of obstructive sleep apnea in children with CF in stable condition, associated with a mild level of sleep disruption. Early routine nocturnal respiratory monitoring is advised in children with CF.

Objective: To assess the safety of the quadrivalent human papillomavirus vaccine (HPV4) in females following routine administration.

Design: In a cohort of vaccinated females, we compared the risk of emergency department visits and hospitalizations during the interval soon after vaccination with risk during a comparison interval more remote from vaccination.

Setting: Kaiser Permanente in California.

Participants: All females who received the HPV4 vaccine.

Main exposure: One or more doses of HPV4 between August 2006 and March 2008.

Main outcome measures: Outcomes were emergency department visits and hospitalizations, grouped into predefined diagnostic categories. Within diagnostic groups, we used odds ratios (ORs) to estimate whether each subject had any outcome in postvaccination risk intervals (days 1-60, days 1-14, and day 0), compared with a control interval distant in time from vaccination.

Results: One hundred eighty-nine thousand six hundred twenty-nine females received at least 1 dose and 44 001 received 3 HPV4 doses. Fifty categories had significantly elevated ORs during at least 1 risk interval. Medical record review revealed that most diagnoses were present before vaccination or diagnostic workups were initiated at the vaccine visit. Only skin infections during days 1 to 14 (OR, 1.8; 95% CI, 1.3-2.4) and syncope on day of vaccination (OR, 6.0; 95% CI, 3.9-9.2) were noted by an independent Safety Review Committee as likely associations with HPV4.

Conclusions: The quadrivalent human papillomavirus vaccine was associated with same-day syncope and skin infections in the 2 weeks after vaccination. This study did not detect evidence of new safety concerns among females 9 to 26 years of age secondary to vaccination with HPV4.

Objective: To use information about prevalence, cost, and variation in resource utilization to prioritize comparative effectiveness research topics in hospital pediatrics.

Design: Retrospective analysis of administrative and billing data for hospital encounters.

Setting: Thirty-eight freestanding US children's hospitals from January 1, 2004, through December 31, 2009.

Participants: Children hospitalized with conditions that accounted for either 80% of all encounters or 80% of all charges.

Main outcome measures: Condition-specific prevalence, total standardized cost, and interhospital variation in mean standardized cost per encounter, measured in 2 ways: (1) intraclass correlation coefficient, which represents the fraction of total variation in standardized costs per encounter due to variation between hospitals; and (2) number of outlier hospitals, defined as having more than 30% of encounters with standardized costs in either the lowest or highest quintile across all encounters.

Results: Among 495 conditions accounting for 80% of all charges, the 10 most expensive conditions accounted for 36% of all standardized costs. Among the 50 most prevalent and 50 most costly conditions (77 in total), 26 had intraclass correlation coefficients higher than 0.10 and 5 had intraclass correlation coefficients higher than 0.30. For 10 conditions, more than half of the hospitals met outlier hospital criteria. Surgical procedures for hypertrophy of tonsils and adenoids, otitis media, and acute appendicitis without peritonitis were high cost, were high prevalence, and displayed significant variation in interhospital cost per encounter.

Conclusions: Detailed administrative and billing data can be used to standardize hospital costs and identify high-priority conditions for comparative effectiveness research--those that are high cost, are high prevalence, and demonstrate high variation in resource utilization.