Role of anticardiolipin antibodies in young persons with migraine and transient focal neurologic events: a prospective study

OBJECTIVES: The aim of this study was to determine the relative risks of pediatric diagnostic, interventional and electrophysiologic catheterizations. BACKGROUND: The role of the pediatric catheterization laboratory has evolved in the last decade as a therapeutic modality, although remaining an important tool for anatomic and hemodynamic diagnosis. METHODS: A study of 4,952 consecutive pediatric catheterization procedures was undertaken. RESULTS: Patient ages ranged from 1 day to 20 years (median 2.9 years). One or more complications occurred in 436 studies (8.8%) and were classified as major in 102 and minor in 458, with vascular complications (n=189; 3.8% of procedures) the most common adverse event. Arrhythmic complications (n=24) were the most common major complication. Death occurred in seven cases (0.14%) as a direct complication of the procedure and was more common in infants (n=5). Independent risk factors for complications included a young patient age and undergoing an interventional procedure. CONCLUSIONS: Complications continue to be associated with pediatric cardiac catheterization. Efforts should be directed to improving equipment for flexibility and size, and finding alternative methods for vascular access. Patient age and interventional studies are risk factors for morbidity and mortality.     

Intraosseous infusion performed in the prehospital setting: South Carolina's six-year experience

Our data do not demonstrate that a prehospital intraosseous infusion protocol will improve the outcome of prehospital pediatric patients with cardiac arrest. The number of patients in our study is too small to allow us to draw a conclusion as to the effect of intraosseous infusion on altering survivability of pediatric cardiac arrest in the prehospital setting. More study is necessary to determine whether there might be a group of pediatric patients with cardiac arrest or hypovolemic shock who could potentially benefit in a prehospital setting from this procedure.     

The impact of a grief workshop for pediatric oncology nurses on their grief and perceived stress

Coping with the death of a pediatric patient with whom the nurses has developed a close relationship is reported by nurses as the most stressful experience of being a pediatric nurse. Such losses are inevitable for a pediatric nurse regardless of subspecialty and can contribute to a nurse leaving the specialty or the discipline. To prevent those consequences, nurses' grief needs to be acknowledged, and their grieving needs to be facilitated. The purpose of this study was to determine the impact of a grief workshop on grief symptoms and perceived stress in two groups of pediatric oncology nurses who differed in years of experience in the specialty. Study findings indicated that the workshop affected the two groups differently, with the more experienced nurses reporting significantly higher stress levels after the workshop than did the less experienced nurses. Study findings are interpreted and recommendations for future work are offered.     

Fluid resuscitation in live Escherichia coli shock in puppies

The infusion of live E. coli in the puppy produces a severe and usually lethal model of pediatric septic shock with characteristic reduction in cardiac output and blood pressure. Hemodynamic abnormalities are partially reversed with fluid resuscitation alone, and large volumes, supplemented with albumin well within tolerated fluid loads, produce the most pronounced corrections of these derrangements. Certain metabolic changes appear to be unique to the young animal and their correction is less successful regardless of resuscitation regimen. These findings suggest that the initial fluid management of the bacteremic pediatric patient should include Ringer's lactate and 5% albumin at approximately 105% of patient's blood volume. Further resuscitation fluid, as well as the role of steroids and antibiotics, remain work currently being carried out in our laboratory.     

Increasing tidal volumes and pulmonary overdistention adversely affect pulmonary vascular mechanics and cardiac output in a pediatric swine model

OBJECTIVES: In a pediatric swine model, the effects of increasing tidal volumes and the subsequent development of pulmonary overdistention on cardiopulmonary interactions were studied. The objective was to test the hypothesis that increasing tidal volumes adversely affect pulmonary vascular mechanics and cardiac output. An additional goal was to determine whether the effects of pulmonary overdistention are dependent on delivered tidal volume and/or positive end-expiratory pressure (PEEP, end-expiratory lung volume). DESIGN: Prospective, randomized, controlled laboratory trial. SETTING: University research laboratory. SUBJECTS: Eleven 4- to 6-wk-old swine, weighing 8 to 12 kg. INTERVENTIONS: Piglets with normal lungs were anesthetized, intubated, and paralyzed. After median sternotomy, pressure transducers were placed in the right ventricle, pulmonary artery, and left atrium. An ultrasonic flow probe was placed around the pulmonary artery. MEASUREMENTS AND MAIN RESULTS: The swine were ventilated and data were collected with delivered tidal volumes of 10, 15, 20, and 25 mL/kg and PEEP settings of 5 and 10 cm H2O in a random order. Pulmonary overdistention was defined as a decrease in dynamic compliance of > or =20% when compared with a compliance measured at a baseline tidal volume of 10 mL/kg. At this baseline tidal volume, airway pressure-volume curves did not demonstrate pulmonary overdistention. Tidal volumes and airway pressures were measured by a pneumotachometer and the Pediatric Pulmonary Function Workstation. Inspiratory time (0.75 sec), FIO2 (0.3), and minute ventilation were held constant. We evaluated the pulmonary vascular and cardiac effects of the various tidal volume and PEEP settings by measuring pulmonary vascular resistance, pulmonary characteristic impedance, and cardiac output. When compared with a tidal volume of 10 mL/kg, a tidal volume of 20 mL/kg resulted in a significant decrease in dynamic compliance from 10.5 +/- 0.9 to 8.4 +/- 0.6 mL/cm H2O (p = .02) at a constant PEEP of 5 cm H2O. The decrease in dynamic compliance of 20% indicated the presence of pulmonary overdistention by definition. As the tidal volume was increased from 10 to 20 mL/kg, pulmonary vascular resistance (1351 +/- 94 vs. 2266 +/- 233 dyne x sec/cm5; p = .004) and characteristic impedance (167 +/- 12 vs. 219 +/- 22 dyne x sec/cm5; p = .02) significantly increased, while cardiac output significantly decreased (951 +/- 61 vs. 708 +/- 48 mL/min; p = .001). Each of these effects of pulmonary overdistention were further magnified when the tidal volume was increased to 25 mL/kg. The tidal volume-induced alterations in pulmonary vascular mechanics, characteristic impedance, and cardiac output occurred to a greater degree when the PEEP was increased to 10 cm H2O. Pulmonary vascular resistance and characteristic impedance were significantly increased and cardiac output significantly decreased for all tidal volumes studied at a PEEP of 10 cm H2O as compared with 5 cm H2O. CONCLUSIONS: Increasing tidal volumes, increasing PEEP levels, and the development of pulmonary overdistention had detrimental effects on the cardiovascular system by increasing pulmonary vascular resistance and characteristic impedance while significantly decreasing cardiac output. Delivered tidal volumes of >15 mL/kg should be utilized cautiously. Careful monitoring of respiratory mechanics and cardiac function, especially in neonatal and pediatric patients, is warranted.     

Infant temperament and cardiac vagal tone: assessments at twelve weeks of age

Sixty 12-week-old infants participated in a laboratory study to explore the relations between temperament and cardiac vagal tone. Temperament was evaluated via laboratory observations and maternal ratings. Cardiac vagal tone, measured as the amplitude of respiratory sinus arrhythmia, was quantified from beat-to-beat heart period data collected during a resting baseline period and during the laboratory assessment of temperament. Specific hypotheses were investigated relating temperament to both basal cardiac vagal tone and changes in cardiac vagal tone during social/attention challenges. Infants with higher baseline cardiac vagal tone were rated in the laboratory as showing fewer negative behaviors and were less disrupted by the experimental procedure. Infants who decreased cardiac vagal tone during the laboratory assessment were rated on maternal report temperament scales as having longer attention spans, and being more easily soothed.     

Cardiac contusion in a 2 1/2-year-old child

This case was unique in that we were seeing signs and symptoms of a cardiac contusion 11 hours after injury, when cellular edema was causing lethal bradyarrhythmias and hypotension. Keeping the possibility of a cardiac contusion in mind when caring for pediatric patients with trauma and including a 12-lead EKG more routinely for pediatric patients with chest trauma would increase identification of potential problems as early as possible. Although cardiac contusion is not common in children, it must not be overlooked.     

Effects of chemotherapy and irradiation on the gonads

As the survival of children with cancer improves, attention must now be focused on understanding and preventing long-term toxicities of treatment and improving the quality of survival. Gonadal toxicity is relatively common, particularly with radiation therapy and alkylating agents. Continued research into the pathogenesis and prevention of gonadal toxicities needs to be included in future treatment strategies for childhood cancer. This will require a multidisciplinary approach with input from pediatric hematologist/oncologists, radiation oncologists, and pediatric endocrinologists.     

Protein splicing: its chemistry and biology

The adult heart depends largely on salvage synthesis to supply its 5'-nucleotide needs. Previous work from this laboratory established that guanosine is metabolized into guanine 5'-nucleotides in heart cells, but that salvage rates are very slow as compared to adenosine. The author hypothesized that guanosine salvage is regulated according to the needs of the cell for guanine nucleotides. This hypothesis was tested using cardiac myocytes which were rendered anoxic for 0-60 min. During this anoxic period, guanine nucleotides were depleted about 50%. At 0, 30, and 60 min, aliquots were removed for cell counting and nucleotide analysis; 50 microM 3H-guanosine was then added and the incubation continued for 1 min. The cells were then extracted and assayed for radioactivity in the guanine nucleotide products. Anoxia for 60 min, depressed GTP levels by 89%, total guanine nucleotides by 50%, and short-term guanosine salvage by 48% over aerobic controls. Reoxygenation of the myocytes after 30 min of anoxia returned guanosine salvage rates to nearly normal (87% of control). Preincubation of the myocytes with 5 mM ribose for times up to 1 hour modestly increased salvage rates of guanosine in aerobic cells. These results suggest that guanosine salvage in cardiac myocytes is not regulated by the size of the guanine nucleotide pool (that is, not sensitive to the demand for guanine nucleotides). Instead, salvage of guanosine is probably limited by cytosolic levels of ATP or phosphoribosylpyrophosphate, the production of which are dependent on adequate oxygen supplies.     

Restructuring the Undergraduate Laboratory Instructional Process

There is little doubt that a laboratory experience can be a beneficial component of the undergraduate engineering learning process. Observing physical demonstrations of textbook and lecture information can enhance a student’s perception of a concept and produce clarity of key issues. Unfortunately, limitations often exist that constrain the developing laboratories and sometimes reducing the student’s experience to little more than performing “cookbook” experiments and copying previous lab reports; an exercise that benefits neither the instructor nor the student. This paper summarizes an alternative approach for undergraduate laboratory instruction that relies on the undergraduate students working in teams to design and conduct experiments. The instructor acts as mentor to a process that ensures a quality laboratory exercise without being the sole responsible party. The students’ learning is increased and the laboratory experience is enhanced due, in part, to the experiments being designed by students and for students; matching students’ needs, education, and interests with experiments. An additional benefit comes from participants being immersed into the concepts of experimental design and analysis using a team of peers.     

A study to investigate the needs of relatives of patients on a cardiothoracic ICU, following routine cardiac surgery

The purpose of this study was to investigate the needs of relatives of patients on a cardiothoracic ICU, as perceived by themselves. An exploratory research design was used--a modified replication of a study carried out by Molter (1979) in the USA. Data were collected from a sample of convenience consisting of 14 relatives of patients who had been on a cardiothoracic ICU, following routine cardiac surgery. Subjects were presented with a list of 45 need statements, which they were asked to rank by importance, to identify whether they perceived these needs to have been met, and to determine who was involved in meeting these needs. Data were analysed by the chi-squared test. The 12 most important needs were all perceived to have been met 64.3% or more of the time. Most needs were met by nurses.     

Perioperative management of the pediatric patient

Children are not just small adults. Perioperative nurses working with pediatric patients plan nursing interventions based on established principles of perioperative practice as well as incorporating concepts of growth and development relating to the child. A thorough assessment of the pediatric patient prior to surgery enables the perioperative nurse to plan for the surgical procedure, modifying as need be for the individual patient's specific needs. With adequate preparation, communication, and emotional support, the pediatric surgical experience can be positive for the child, parents, and perioperative team.     

Traditional and alternative research designs and methods in clinical pediatric psychopharmacology

OBJECTIVE: To review both traditional and alternative research designs and methods in pediatric psychopharmacology. METHOD: Study designs used in clinical trials in psychiatry were selected for review with the special considerations of pediatric psychopharmacological trials in mind. Where possible, a reference to a specific published trial in pediatric psychopharmacology was provided for each design. RESULTS: It appears that pediatric psychopharmacology trials require a relatively greater flexibility in design to avoid significant study biases. Alternative research designs may be preferable to the traditional approaches, particularly when the use of the latter may raise important issues of feasibility. CONCLUSIONS: Evolution of a clinical research hypothesis to a study protocol in pediatric psychopharmacology is a manageable task if one keeps in mind essential elements such as selection of study design, population, sample size, treatment duration, and efficacy assessments.     

Hearing aid outcome measures for children

The provision of appropriate amplification for a young hearing-impaired child is critical as the aided speech signal will be used for the development of speech and language. The purpose of this paper is to provide an overview of the complex issues surrounding the documentation of hearing aid outcomes in the pediatric population. In the first two sections of the paper, the unique characteristics and needs of the pediatric population and factors complicating the measurement of outcome are described in detail. The third section provides a review of literature on existing outcome measures for children and the fourth section is devoted to a discussion of alternative approaches. The final section is an overview of clinical and research needs in the area of hearing aid outcome measures for children.     

Development of a blood cardioplegia delivery system for children

We have developed a blood cardioplegia delivery system for children. Essential points of a delivery system in pediatric cardiac surgery are (1) a small amount of priming volume of a delivery system, and (2) slow, steady infusion of a cardioplegic solution. We changed a heat exchanger to a smaller one for reduction of priming volume, and changed a roller pump tube to a smaller one for slow, steady infusion. Thus, priming volume of a delivery system has reduced from 180 to 100 ml, and we can infuse a cardioplegic solution at a steady rate less than 10 ml/min. Our clinical experience with this system suggests that this blood cardioplegia delivery system is useful for pediatric cardiac surgery.     

Animal-induced injuries and disease, neonatal jaundice, immunizations, and viral infections

Highlights from the past years' literature on the topics of animal-induced injuries and diseases, neonatal jaundice, immunizations, and viral infections are discussed from the perspective of the general pediatrician. An effort is made to place recent advances in care or understanding of clinical problems into the context of the pediatric office practice. The current reality of health care-be it managed care, care for the underserved, or the recent pressures on academic and hospital-based medicine-does not alter the importance of the delivery of quality care at the office level. Although it is now popular to define quality of health care in cute advertising copy, as if we are selling durable goods, excellence in pediatric office-based practice continues to require broad strokes of medical knowledge coupled with a unswerving commitment to and advocacy for the needs and well-being of infants, children, and young adults.     

On the Distributors and Design Criteria for Gas-Solid and,Gas-Liquid-Solid Fluidized Beds

Fluidized beds are well known for their versatile applications in chemical, metallurgical, mineral and bio - processing industries. Inspite of their several potential uses, the design and selection of the fluidized bed reactor is still empirical. One of the key parts which influences the reactor performance is the distributor/grid which has been recognized as the heart of the fluidized system. Distributor also called grid in fluidized bed plays a vital role in assessing the hydrodynamics and performance of the reactor. Though the importance of the distributor has long since been recognized, not much seems to have been done on basics of its design aspects. In the context of significant developments that have taken place in the field in the last decade the need exists for a comprehensive review updating the available information on the role of distributors and their design for the fluid bed system. Hence a state-of-the-art review of a wide range of distributors/grids has been attempted in this paper and the need for careful consideration of the design principles is discussed. Prediction of operating flow rates as influenced by distributors, pressure drop criteria pertinent to stability of operation, the choice of grids or distributors and their types from laboratory scale to commrecial size units, design models and the role of plenum chamber and pumping requirements are all critically reviewed and analyzed. Nomographs for the distributor design and the scope for future research stressing the immediate needs are presented.     

The educational needs of myocardial infarction patients

Over the last 20 years, the educational needs of myocardial infarction (MI) patients have been addressed from the points of view of health care providers and patients. However, most teaching is based on the health care providers' perceptions of patients' educational needs. Little emphasis has been placed on patients' perception of educational needs. This article identifies the MI patients' perceived learning needs in the coronary care unit, in the post-coronary care unit, and at home, and evaluates the extent of the effectiveness of various types of cardiac rehabilitation programs. Recommendations for educating first-time MI patients during each phase of cardiac recovery and for conducting future research studies are discussed.     

Implementing the Agency for Health Care Policy and Research pain management pediatric guideline in a multicultural practice setting

This article describes the implementation, monitoring, and evaluation of a clinical practice guideline for managing pediatric patient pain. The standard of care used was the Agency for Health Care Policy and Research acute pain management guideline. It was used to assess current levels of care and to make recommendations for improvements. Information was gathered from a sample of 240 pediatric patients aged 1 week to 14 years. Recommendations for improving care are given. The guideline was found to be clinically useful as a general standard of care, but more work needs to be done to individualize care for specific populations, age groups, and cultures.     

Increased mortality after successful treatment for Hodgkin's disease

PURPOSE: To determine the impact of treatment toxicity on long-term survival in pediatric Hodgkin's disease. PATIENTS AND METHODS: We studied late events in 387 patients treated for pediatric Hodgkin's disease on four consecutive clinical trials at St Jude Children's Research Hospital from 1968 to 1990. Relative risks, actuarial risks, and absolute excess risks for cause-specific deaths were calculated. RESULTS: As of April 1997, 316 (82%) of patients were alive, with a median follow-up of 15.1 (range, 2.9 to 28.6) years. In this cohort, which represented 5,623 person-years of follow-up, 71 fatal events resulted from Hodgkin's disease (n=36), second malignancies (n=14), infections (n=7), accidents (n=7), cardiac disease (n=6), and asphyxiation (n=1). The 5-year estimated event-free survival (EFS) for the entire cohort was 79.6%+/-2.1 %, which declined to 63.1%+/-4.4% by 20 years. Cumulative incidences of cause-specific deaths at 25 years were 9.8%+/-1.6% for Hodgkin's disease, 8.1%+/-2.6% for second malignancy, 4.0%+/-1.8% for cardiac disease, 3.9%+/-1.5% for infection, and 2.1%+/-0.8% for accidents. Standardized incidence ratios showed excess risk for all second malignancies (12; 95% confidence interval [CI], 8 to 17), acute myeloid leukemia (81; 95% CI, 16 to 237), solid tumors (11; 95% CI, 7 to 16), and breast cancer (33; 95% CI, 12 to 72). Standardized mortality ratios also showed excess mortality from cardiac disease (22; 95% CI, 8 to 48) and infection (18; 95% CI, 7 to 38). CONCLUSION: Compared with age- and sex-matched control populations, survivors of pediatric Hodgkin's disease who were treated before 1990 face an increased risk of early mortality related to second cancers, cardiac disease, and infection.