Bernhard L. Wiedermann

Rates of medication errors among depressed and burnt out residents: prospective cohort study

Objective To determine the prevalence of depression and burnout among residents in paediatrics and to establish if a relation exists between these disorders and medication errors. Design Prospective cohort study. Setting Three urban freestanding children’s hospitals in the United States. Participants 123 residents in three paediatric residency programmes. Main outcome measures Prevalence of depression using the Harvard national depression screening day scale, burnout using the Maslach burnout inventory, and rate of medication errors per resident month. Results 24 (20%) of the participating residents met the criteria for depression and 92 (74%) met the criteria for burnout. Active surveillance yielded 45 errors made by participants. Depressed residents made 6.2 times as many medication errors per resident month as residents who were not depressed: 1.55 (95% confidence interval 0.57 to 4.22) compared with 0.25 (0.14 to 0.46, P<0.001). Burnt out residents and non-burnt out residents made similar rates of errors per resident month: 0.45 (0.20 to 0.98) compared with 0.53 (0.21 to 1.33, P=0.2). Conclusions Depression and burnout are major problems among residents in paediatrics. Depressed residents made significantly more medical errors than their non-depressed peers; however, burnout did not seem to correlate with an increased rate of medical errors.

Renal Scarring Following Reflux and Nonreflux Pyelonephritis in Children: Evaluation with 99mTechnetium-Dimercaptosuccinic Acid Scintigraphy

99mTechnetium dimercaptosuccinic acid (DMSA) scintigraphy is the imaging modality of choice for the detection of acute pyelonephritis and chronic renal scarring in children. Using the DMSA scan we prospectively evaluated renal scarring after reflux and nonreflux pyelonephritis in children. The study population consisted of 33 patients with acute pyelonephritis documented by a DMSA renal scan at infection. The children were evaluated for renal scarring with a followup DMSA scan 4 to 42 months (mean 10.7 months) after the acute infection. All new scarring on followup DMSA scans occurred at sites corresponding exactly to areas of acute inflammation on the initial DMSA scan. Therefore, only those kidneys with acute changes on the initial scan were subsequently analyzed. Of 38 kidneys new or progressive scarring developed in 16 (42%), including 6 of 15 (40%) with associated vesicoureteral reflux and 10 of 23 (43%) without demonstrable reflux. New renal scarring developed in 6 of the 7 kidneys (86%) associated with a neuropathic bladder or posterior urethral valves. In contrast, new scarring developed in only 10 of 31 kidneys (32%) associated with a normal bladder (p = 0.028). Excluding the kidneys associated with a neuropathic bladder or posterior urethral valves, new renal scarring developed in 3 of 12 (25%) with primary reflux, compared with 7 of 19 (37%) without vesicoureteral reflux. Except for the white blood count and the species of infecting bacteria, no other statistically significant differences could be found between those cases in which scars did or did not develop. We conclude that acquired renal scarring only occurs at sites corresponding to previous areas of acute pyelonephritis, the acute parenchymal inflammatory changes of acute pyelonephritis are reversible and do not lead to new renal scarring in the majority of cases, and once acute pyelonephritis has occurred ultimate renal scarring is independent of the presence or absence of vesicoureteral reflux.

Relationship among vesicoureteral reflux, P-fimbriated Escherichia coli, and acute pyelonephritis in children with febrile urinary tract infection

Ninety-four children with febrile urinary tract infection were studied prospectively to determine the relationship between vesicoureteral reflux, P-fimbriated Escherichia coli, and acute pyelonephritis, and to evaluate the diagnostic reliability of commonly used clinical and laboratory observations. By using renal scan with dimercaptosuccinic acid labeled with technetium 99m as the standard of reference, we documented acute pyelonephritis in 62 (66%) of 94 patients. Vesicoureteral reflux was demonstrated in 29 (31%) of the total group and in only 23 (37%) of 62 patients with pyelonephritis. Of the 70 E. coli urinary isolates, 48 (69%) were P-fimbriated, including 30 (64%) of 47 isolates from patients with pyelonephritis and 18 (78%) of 23 isolates from patients with normal renal scans. The prevalence of P-fimbriated E. coli in patients with pyelonephritis and vesicoureteral reflux was 46%, compared with 71% in those with pyelonephritis who had no concurrent vesicoureteral reflux (p = 0.222). Multiple clinical and laboratory variables commonly used in the diagnosis of acute pyelonephritis did not adequately predict the presence or absence of parenchymal involvement. These data show the following: (1) Acute pyelonephritis in the absence of demonstrable vesicoureteral reflux is common. (2) Febrile urinary tract infections in children are commonly associated with P-fimbriated E. coli, both in the presence and absence of vesicoureteral reflux. (3) The presence of P fimbriae alone does not fully explain the pathophysiology of renal parenchymal invasion by bacteria in the absence of vesicoureteral reflux. (4) The diagnosis of acute pyelonephritis in children with febrile urinary tract infections on the basis of clinical and laboratory observations is unreliable.

Effects of the accreditation council for graduate medical education duty-hour limits on sleep, work hours, and safety.

OBJECTIVE. To mitigate the risks of fatigue-related medical errors, the Accreditation Council for Graduate Medical Education introduced work hour limits for resident physicians in 2003. Our goal was to determine whether work hours, sleep, and safety changed after implementation of the Accreditation Council for Graduate Medical Education standards. METHODS. We conducted a prospective cohort study in which residents from 3 large pediatric training programs provided daily reports of work hours and sleep. In addition, they completed reports of near-miss and actual motor vehicle crashes, occupational exposures, self-reported medical errors, and ratings of educational experience. They were screened for depression and burnout. Concurrently, at 2 of the centers, data on medication errors were collected prospectively by using an established active surveillance method. RESULTS. A total of 220 residents provided 6007 daily reports of their work hours and sleep, and 16 158 medication orders were reviewed. Although scheduling changes were made in each program to accommodate the standards, 24- to 30-hour shifts remained common, and the frequency of residents’ call remained largely unchanged. There was no change in residents’ measured total work hours or sleep hours. There was no change in the overall rate of medication errors, and there was a borderline increase in the rate of resident physician ordering errors, from 1.06 to 1.38 errors per 100 patient-days. Rates of motor vehicle crashes, occupational exposures, depression, and self-reported medical errors and overall ratings of work and educational experiences did not change. The mean length of extended-duration (on-call) shifts decreased 2.7% to 28.5 hours, and rates of resident burnout decreased significantly (from 75.4% to 57.0%). CONCLUSIONS. Total hours of work and sleep did not change after implementation of the duty hour standards. Although fewer residents were burned out, rates of medication errors, resident depression, and resident injuries and educational ratings did not improve.

Urinary interleukin-6 and interleukin-8 in children with urinary tract infection

Abstract Urinary interleukin-6 (UIL-6) and urinary interleukin-8 (UIL-8) concentrations were measured by immunoassay in 39 and 34 patients respectively, hospitalized with febrile urinary tract infection (UTI), and in 37 and 32 age-, race- and sex-matched febrile control children respectively, with negative urine cultures. UIL-6 and UIL-8 concentrations, measured in picograms per milliliter and corrected for creatinine, were compared with clinical and laboratory indicators of inflammation and bacterial virulence factors of Escherichia coli. Median UIL-6 concentrations at the time of admission were 397 pg/ml (range 0–65,789 pg/ml) in the 37 patients compared to 0 pg/ml (range 0–473.8 pg/ml) in the 37 controls (P<0.0001). Median UIL-8 concentrations at the time of admission were 5809 pg/ml (range 0–347,368 pg/ml) in the 32 patients compared to 0 pg/ml (range 0–2231 pg/ml) in the 32 controls (P<0.0001). UIL-6 and UIL-8 concentrations were lower (P<0.0001 for UIL-6 and P=0.0005 for UIL-8) in follow-up urine samples from UTI patients, obtained 48 h after the initiation of antibiotic therapy. UIL-6 and UIL-8 concentrations were statistically significantly correlated with urine white blood cells (WBC). UIL-8 concentrations were elevated in patients with E. coli organisms producing hemolysin. UIL-6 and UIL-8 are elevated in children with febrile UTI and decrease in response to antibiotic therapy. Magnitude of UIL-8 response is associated with hemolysin production, a bacterial virulence factor of E. coli. UIL-6 and UIL-8 concentrations are statistically correlated with urine WBC. UIL-6 and UIL-8 may be mediators of inflammation in children with febrile UTI.

Treatment of intracranial abscesses associated with sinusitis in children and adolescents

We retrospectively reviewed the management of intracranial abscesses associated with sinusitis in 13 children and adolescents by reviewing medical records and computed tomography (CT) scans of a consecutive case series. The mean duration of follow-up was 4.5 years with a range of 1.3 to 8.6 years, and the setting was a major metropolitan childrens hospital providing primary as well as tertiary care. All patients received antibiotics (most commonly chloramphenicol, 75 to 100 mg/kg/day, in combination with oxacillin, 150 to 200 mg/kg/day) to which the sinus and intracranial organisms are susceptible. Surgical drainage of loculated infection was done for patients with acute neurologic symptoms or signs and for those patients whose abscesses enlarged during medical therapy. Three patients underwent immediate drainage of intracranial abscesses because of acute neurologic signs and symptoms. Sequential CT scans demonstrated enlargement of the intracranial abscesses in the remaining 10 patients. This apparent failure of medical management could not be explained by duration of symptoms before therapy, size of lesion, choice of antibiotics, or use of steroids. No child was successfully treated with antibiotics alone. Successful management consisted of antibiotic therapy combined with surgical drainage of loculated infection. This approach to therapy is preferred for all children with intracranial abscess associated with sinusitis.

Human parechovirus-3 infection: emerging pathogen in neonatal sepsis.

Human parechovirus-3 (HPeV-3) is an emerging pathogen that has been described as a cause of neonatal sepsis. Human parechoviruses are a family of viruses closely related to enteroviruses; however, enteroviral PCR will not detect HPeVs. We present clinical details of neonatal meningoencephalitis and hepatitis-coagulopathy syndrome caused by HPeV-3 infection.

Association of Lewis blood group phenotypes with urinary tract infection in children.

Many blood group antigens, genetically controlled carbohydrate molecules, are found on the surface of uroepithelial cells and may affect bacterial adherence and increase the frequency of urinary tract infection (UTI) in adults. Sixty-two children aged 2 weeks to 17 years (mean, 2.3 years) who were hospitalized with fever in association with UTIs caused by Escherichia coli had complete (n = 50) or partial (n = 12) erythrocyte antigen typing to determine the role of erythrocyte antigens and phenotypes in UTI in children; 62 healthy children undergoing nonurologic elective surgery, matched 1 to 1 for age, sex, and race to the patient group, formed the control group. In univariate tests, patients and control subjects did not differ in ABO, Rh, P, Kell, Duffy, MNSs, and Kidd systems by the McNemar test of symmetry (p > 0.05). The frequency of the Lewis (Le) (a-b-) phenotype was higher (16/50 vs 5/50; p = 0.0076) and the frequency of the Le(a + b +) phenotype was lower (8/50 vs 16/50; p = 0.0455) in the patient population than in the control subjects. A stepwise logistic regression model to predict UTI with the explanatory variables A, B, O, M, N, S, s, Pl, Lea, and Leb showed that only the Lea and Leb antigens entered the model with p < 0.1. The Le(a-b-) phenotype was associated with UTI in this pediatric population. The relative risk of UTI in children with the Le(a-b-) phenotype was 3.2 (95% confidence interval, 1.3 to 7.9). Specific blood group phenotypes in pediatric populations may provide a means to identify children at risk of having UTI.

Immunogenicity and safety of Haemophilus influenzae type b-tetanus protein conjugate vaccine alone or mixed with diphtheria-tetanus-pertussis vaccine in infants☆☆☆★

Haemophilus capsular polysaccharide-tetanus toxoid conjugate (PRP-T) and diphtheria-tetanus-pertussis (DTP) vaccines were administered in a single syringe (group 1) or separate syringes (group 2) to 284 infants at 2, 4, and 6 months of age. Group 1 infants had a slightly greater incidence of local reactions. Systemic reactions were similar. The geometric mean titers of polyribosylribitol phosphate (PRP) serum antibody concentrations after the third dose of PRP-T vaccine were 4.8 and 4.3 micrograms/ml for groups 1 and 2, respectively. Antibody responses to DTP antigens were also similar. The immunogenicity and safety of the PRP-T and DTP vaccines are equivalent when the vaccines are administered in separate syringes or the same syringe to infants.

Urinary N-acetyl-beta-glucosaminidase and beta-2-microglobulin in the diagnosis of urinary tract infection in febrile infants.

Urinary N-acetyl-beta-glucosaminidase (NAG) and beta-2-microglobulin (B2M) concentrations were measured in 24 pediatric patients with febrile urinary tract infection (UTI) and compared with the technetium-99m-labeled dimercaptosuccinic acid (DMSA) renal scan results, in order to evaluate a noninvasive means to localize the site of UTI. Increased urinary B2M and NAG were not associated with renal inflammation (pyelonephritis), as defined by positive dimercaptosuccinic acid scan. Median NAG concentrations were 114.2 mumol/hour/mg creatinine (CR) (range, 5.7 to 305.4) in 17 febrile UTI patients vs. 13.8 (range, 3.4 to 104.3) in 17 age and sex-matched febrile controls with negative urine cultures, P = 0.0001. The sensitivity and specificity of NAG > or = 40 mumol/hour/mg of CR in predicting UTI in febrile patients, regardless of the site of infection, were 88 and 88%, respectively. Increased urinary NAG is associated with UTI in febrile patients regardless of the level of infection (scan status), and may be an informative indicator of UTI.