Archives of pediatrics & adolescent medicine最新文献

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.

Objective: To investigate the association of prenatal mercury exposure and fish intake with attention-deficit/hyperactivity disorder (ADHD)-related behavior.

Methods: For a population-based prospective birth cohort recruited in New Bedford, Massachusetts (1993-1998), we analyzed data for children examined at age 8 years with peripartum maternal hair mercury measures (n = 421) or maternal report of fish consumption during pregnancy (n = 515). Inattentive and impulsive/hyperactive behaviors were assessed using a teacher rating scale and neuropsychological testing.

Results: The median maternal hair mercury level was 0.45 μg/g (range, 0.03-5.14 μg/g), and 52% of mothers consumed more than 2 fish servings weekly. In multivariable regression models, mercury exposure was associated with inattention and impulsivity/hyperactivity; some outcomes had an apparent threshold with associations at 1 μg/g or greater of mercury. For example, at 1 μg/g or greater, the adjusted risk ratios for mild/markedly atypical inattentive and impulsive/hyperactive behaviors were 1.4 (95% CI, 1.0-1.8) and 1.7 (95% CI, 1.2-2.4), respectively, for an interquartile range (0.5 μg/g) mercury increase; there was no confounding by fish consumption. For neuropsychological assessments, mercury and behavior associations were detected primarily for boys. There was a protective association for fish consumption (>2 servings per week) with ADHD-related behaviors, particularly impulsive/hyperactive behaviors (relative risk = 0.4; 95% CI, 0.2-0.6).

Conclusions: Low-level prenatal mercury exposure is associated with a greater risk of ADHD-related behaviors, and fish consumption during pregnancy is protective of these behaviors. These findings underscore the difficulties of balancing the benefits of fish intake with the detriments of low-level mercury exposure in developing dietary recommendations in pregnancy.

Objective: To describe the long-term outcomes of pediatric pleural empyema.

Design: Prospective observational study from October 2008 to October 2011.

Setting: Tertiary care children's hospital.

Participants: Children with pleural empyema (loculations and/or septations identified on radiologic imaging or frank pus on thoracentesis).

Main outcome measures: Children were seen 1, 6, and 12 months postdischarge. Outcome measures included symptoms and signs of respiratory disease, child and parental impact, radiographic resolution, spirometry, and health-related quality of life (Pediatric Quality of Life Inventory score). Analysis was based on the last observation carried forward for missing data.

Results: Eighty-two of 88 patients (93%) eligible were recruited. Fifty-four percent were male and mean (SD) age was 4.5 (3.4) years. Outcome data was obtained in 100% at 1 month, 90% at 6 months, and 72% at 1 year. Seventy-one percent had effusions occupying a quarter or more of the hemithorax and 62% of effusions were drained. Fever, cough, parental work loss, child school loss, radiographic abnormalities, and abnormal spirometry results were common in the first month and then declined. By the last observation, 2% of patients had abnormal radiographs (aside from pleural thickening), 6% had mild obstruction on spirometry, and Pediatric Quality of Life Inventory scores were better than for children with asthma (P < .001). Patients with abnormal outcomes in 1 measure had normal outcomes in all other clinical measures.

Conclusions: Clinically important phenomena persist in the short-term, but virtually all children with pleural empyema have no long-term sequelae.

Objective: To determine the emergent literacy and language effects of a low-intensity literacy promotion program (Let's Read) provided via universal well-child services to parents during the first 4 years of their child's life.

Design: Population-based, cluster randomized controlled trial performed between March 1, 2006, and December 10, 2010.

Setting: Maternal and child health centers (clusters) in 5 relatively disadvantaged local government areas in Melbourne, Australia.

Participants: All parents attending their 4-week well-child appointments in participating centers were invited to take part in the study.

Intervention: The Let's Read program was delivered at 4, 12, 18, and 42 months during universal well-child care visits.

Main outcome measure: Child emergent literacy skills (intrasyllabic, phonemic, and sound/letter knowledge) and language (core, receptive, and expressive), measured at 4 years of age.

Results: A total of 630 parents participated, with 365 children in 32 intervention clusters and 265 children in 33 control clusters; 563 children (89.4%) were retained in the study to 4 years of age. The adjusted mean differences (intervention minus control) for emergent literacy was 0.2 (95% CI, -0.2 to 0.6; P = .29) for intrasyllabic units, 0.05 (95% CI, -0.4 to 0.5; P = .85) for phonemic awareness, and 0.1 (95% CI, -1.5 to 1.6; P = .92) for letter knowledge. For language, the differences were 1.6 (95% CI, -1.1 to 4.3; P = .25) for core, 0.8 (95% CI, -2.0 to 3.7; P = .56) for receptive, and 1.4 (95% CI, -1.4 to 4.2; P = .32) for expressive scores.

Conclusion: This population-wide primary care literacy promotion and book distribution program provided neither the anticipated benefits to literacy and language nor enhanced uptake of literacy activities at 4 years of age, even when targeted to relatively disadvantaged areas.

Trial registration: isrctn.org Identifier: ISRCTN04602902.

Objectives: To describe the frequency of different physiologic monitoring modalities and combinations of modalities used during pediatric procedural sedation; to describe how physiologic monitoring varies among different classes of patients, health care providers (ie, ranging from anesthesiologists to emergency medicine physicians to nurse practitioners), procedures, and sedative medications employed; and to determine the proportion of sedations meeting published guidelines for physiologic monitoring. DESIGN This was a prospective, observational study from September 1, 2007, through March 31, 2011.

Setting: Data were collected in areas outside of the operating room, such as intensive care units, radiology, emergency departments, and clinics.

Participants: Thirty-seven institutions comprise the Pediatric Sedation Research Consortium that prospectively collects data on procedural sedation/anesthesia performed outside of the operating room in all children up to age 21 years.

Main outcome measures: Data including demographics, procedure performed, provider level, adverse events, medications, and physiologic monitors used are entered into a web-based system.

Results: Data from 114 855 subjects were collected and analyzed. The frequency of use of each physiologic monitoring modality by health care provider type, medication used, and procedure performed varied significantly. The largest difference in frequency of monitoring use was seen between providers using electrocardiography (13%-95%); the smallest overall differences were seen in monitoring use based on the American Society of Anesthesiologists classifications (1%-10%). Guidelines published by the American Academy of Pediatrics, the American College of Emergency Physicians, and the American Society of Anesthesiologists for nonanesthesiologists were adhered to for 52% of subjects.

Conclusions: A large degree of variability exists in the use of physiologic monitoring modalities for pediatric procedural sedation. Differences in monitoring are evident between sedation providers, medications, procedures, and patient types.