Bonnie L. Burke

Drawing clocks and driving cars.

AbstractOBJECTIVE: The purpose of the study was to determine whether a new method of scoring the Clock Drawing Test (CDT) is a reliable and valid method for identifying older adults with declining driving competence. DESIGN: Prospective cohort study. SETTING: An outpatient driving evaluation clinic. PARTICIPANTS: One hundred nineteen community-dwelling, active drivers with a valid driver’s license, aged 60 and older referred for driving evaluation. MAIN OUTCOME MEASURES: The CDT and a driving test using a STISIM Drive simulator. RESULTS: The CDT showed a high level of accuracy in predicting driving simulation outcome (area under the receiver-operator curve, 0.90; 95% confidence interval, 0.82 to 0.95). CDT scoring scales were comparable and all correlations between CDT scores and driving performance were negative, implying that as the CDT score decreases, the number of errors increases. Interrater reliability of CDT scores was 0.95. Subjects scoring less than 5 out of 7 points on the CDT made significantly more driving errors, hazardous and in total (P<.001). CONCLUSIONS: The CDT can help establish problems with executive function and indicate the need for a formal driving evaluation. Our CDT scoring scale is a reliable, valid, and time-effective screening tool for identifying elderly drivers in need of further evaluation.

A pilot study of the impact of surgical repair on disease-specific quality of life among patients with pectus excavatum.

BACKGROUND This study was conducted to determine the ability of 2 questionnaires (ie, child and parent versions) to measure physical and psychosocial quality-of-life changes after surgical repair of pectus excavatum. METHODS The authors administered these questionnaires by telephone interviews with 22 parents and 19 children (ages 8 to 18) before surgery and 6 to 12 months after repair by the Nuss procedure. RESULTS The instruments had high test-retest reliability (Rho > 0.6 for all retained questions). Children reported significant improvements in exercise intolerance, shortness of breath, and tiredness. Of 9 questions asking the children how they feel or act about their bodies, all but one question showed significant improvement after surgery. Parents also reported significant improvements in their childs exercise tolerance, chest pain, shortness of breath, and tiredness and decreases in the frequency of the child being frustrated, sad, self-conscious, and isolated. CONCLUSIONS These questionnaires appear to be more than adequate to measure disease-specific quality-of-life changes after surgery. These data confirm for the first time that surgical repair of pectus excavatum has a positive impact on both the physical and psychosocial well-being of the child.

Local anesthetic and stylet styles: factors associated with resident lumbar puncture success.

OBJECTIVE. To assess the effects of procedural techniques, local anesthetic use, and postgraduate training level on lumbar puncture (LP) success rates. METHODS. In this prospective observational study, medical students and residents (“trainees”) reported techniques used for infant LPs in an urban teaching emergency department. Data on postgraduate year, patient position, draping, total and trainee numbers of attempts, local anesthetic use, and timing of stylet removal were collected. Logistic regression analysis was used to identify predictors of successful LP, with success defined as the trainee obtaining cerebrospinal fluid with <1000 red blood cells per mm3. RESULTS. We collected data on 428 (72%) of 594 infant LPs performed during the study period. Of 377 performed by trainees, 279 (74%) were successful. Local anesthesia was used for 280 (74%), and 225 (60%) were performed with early stylet removal. Controlling for the total number of attempts, LPs were 3 times more likely to be successful among infants >12 weeks of age than among younger infants (odds ratio [OR]: 3.1; 95% confidence interval [CI]: 1.2–8.5). Controlling for attempts and age, LPs performed with local anesthetic were twice as likely to be successful (OR: 2.2; 95% CI: 1.04–4.6). For infants ≤12 weeks of age, early stylet removal improved success rates (OR: 2.4; 95% CI: 1.1–5.2). Position, drape use, and year of training were not significant predictors of success. CONCLUSIONS. Patient age, use of local anesthetic, and trainee stylet techniques were associated with LP success rates. This offers an additional rationale for pain control. Predictors identified in this study should be considered in the training of physicians, to maximize their success with this important procedure.

Pain, position, and stylet styles: infant lumbar puncture practices of pediatric emergency attending physicians.

Objectives: Lumbar punctures (LPs) are common emergency department (ED) procedures. Few pediatric studies exist to define training, guide practice, or indicate preferred methods for infants. While pain control is recommended, no recent studies indicate prevalence of analgesic use since the advent of topical anesthetics. We surveyed academic pediatric ED physicians to assess training and technique preferences and to highlight pain control usage. Methods: A total of 398 physicians were randomly selected from the 621 e-mail accessible members of the AAP Section on Pediatric Emergency Medicine. Questions concerning physician training, analgesia, and technique were either sent by regular mail or via e-mail link to a Web-based survey. Results: Of 359 deliverable surveys, there were 188 physician responses (52.4%) with differential response rates by survey format [58 e-mail (36%) and 130 regular mail responses (66%); P < 0.05]. Almost a third will advance the needle without the stylet in place. Two-thirds of physicians do not routinely use analgesia for neonatal LPs. Those using pain control were trained more recently (median 12 years vs. 15 years postresidency; P = 0.04). Analgesia use was the most common practice changed since residency. Conclusions: Analgesia is underused for infant LPs. Advancing the needle without a stylet is not uncommon. Response rate to regular mail surveys was much higher.

Reliability of a staging assessment system for recurrent respiratory papillomatosis

INTRODUCTION A staging system for the assessment of severity of disease and response to the therapy in recurrent respiratory papillomatosis (RRP) was proposed several years ago. It includes both a subjective functional assessment of clinical parameters and an anatomic assessment of disease distribution. The anatomic score can then be used in combination with the functional score to measure an individual patients clinical course and response to the therapy over time. In using this system, it would be of benefit to know what level of variability can be expected from one surgeon to another in the assessment of an RRP patient and the assignment of a score. DESIGN Ten videotaped recordings of endoscopic assessments of patients with RRP were reviewed by 15 pediatric otolaryngologists and scored based on the criteria of the staging assessment system. RESULTS Analysis was conducted for 15 raters of scoring severity over 25 sites of 10 patients. The total score is the addition of scores over the 25 sites with a score equal to or greater than 20 representing high risk. For 8/10 (80%) of the subjects, there was a complete agreement about risk categorization (low risk) and agreement by 14/15 (93%) raters for categorization of one other patient. For 9/10 (90%) of subjects, the standard errors of the mean total scores were less than 1, meaning a low variance and subsequent high reliability of the total score. CONCLUSIONS This staging system was able to achieve agreement by 15 pediatric otolaryngologists on 9 of 10 subjects in terms of degree of severity of RRP.

Prevalence of scalp scaling in prepubertal children.

Objective. To determine the prevalence and most common etiologies of scalp scaling in infants and prepubertal children and the specificity of head and neck lymphadenopathy for the diagnosis of tinea capitis associated with scalp scaling. Design/Methods. A cross-sectional study of 300 children, 200 from an urban general pediatric practice and 100 from 2 urban pediatric dermatology practices, was conducted. Half of the subjects were <2 years old, and half were 2 to 10 years old. Demographic data, medical history, and clinical data noting the presence of scalp scaling and other scalp signs and symptoms, as well as adenopathy of the head and neck, were collected. Results. Scalp scaling was seen in 66 (22%) children. There was an insignificantly higher prevalence of scalp scaling in those <2 years old compared with the 2- to 10-year-old group. In those <2 years old with scalp scaling, the most common diagnoses were seborrheic dermatitis (thick, adherent, greasy scale predominantly in the frontal and/or vertex areas of the scalp) and atopic dermatitis/eczema. Among those 2 to 10 years old with scalp scaling, the most common diagnoses were nonspecific (fine, white) scaling, seborrheic dermatitis, and atopic dermatitis/eczema. Nine (3%) patients were culture-positive for a dermatophyte, all of whom were black, and grew Trichophyton tonsurans. More than half (52.7%) of all patients had head and neck adenopathy. The presence of posterior nodes was significantly associated with atopic dermatitis/eczema and marginally associated with a positive dermatophyte culture. The presence of scalp scaling plus posterior adenopathy was significantly associated with seborrheic dermatitis and a positive dermatophyte culture in the entire study population and with atopic dermatitis in the pediatric dermatology clinics. Conclusions. Scalp scaling was common in children 0 to 10 years old. Infantile-type seborrheic dermatitis was noted in both age groups: it was 3 times as likely in children <2 years old (18%) than in those 2 to 10 years old (6%). Contrary to traditional teaching, seborrheic dermatitis can be found in preadolescent children. Atopic dermatitis/eczema was associated with scalp scaling in both age groups. Head and neck adenopathy was very common and nonspecific for any 1 diagnosis. Posterior adenopathy with concurrent scalp scaling was significantly associated with seborrheic dermatitis, a positive dermatophyte culture, and atopic dermatitis. In this nonselected pediatric population, scalp scaling with adenopathy was not associated exclusively with tinea capitis.

Hepatic enzyme decline after pediatric blunt trauma: A tool for timing child abuse?

OBJECTIVES Previous research in adult patients with blunt hepatic injuries has suggested a pattern of serum hepatic transaminase concentration decline. Evaluating this decline after pediatric blunt hepatic trauma could establish parameters for estimating the time of inflicted injuries. Deviation from a consistent transaminase resolution pattern could indicate a developing complication. METHODS Retrospective review of pediatric patients with injuries including blunt liver trauma admitted to one of four urban level 1 trauma centers from 1990 to 2000. Cases were excluded for shock, death within 48 h, complications, or inability to determine injury time. Transaminase concentration decline was modeled by individual patients, by injury grade, and as a ratio with regard to injury time. RESULTS One hundred and seventy-six patients met inclusion criteria. The rate of aspartate aminotransferase (AST) clearance changed significantly over time. Alanine aminotransferase (ALT) fell more slowly. Of the 118 patients who had multiple measurements of AST, for 112 (95%) the first concentration obtained was the highest. When ALT was greater than AST, the injury was older than 12h (97% specificity (95% CI, 95-99%), sensitivity 42% (95% CI, 33-50%)). Patients with enzymes that rose after 14 h post-injury were more likely to develop complications (RR=24, 95% CI 10-58). CONCLUSIONS Hepatic transaminases rise rapidly after uncomplicated blunt liver injury, then fall predictably. Persistently stable or increasing concentrations may indicate complications. ALT>AST indicates subacute injury.

Novel Motor and Somatosensory Activity Is Associated With Increased Cerebral Cortical Blood Volume Measured by Near-Infrared Optical Topography

Recent reports suggest that learning is enhanced by emotion, spontaneity, and play. The mechanisms of this enhancement are unclear and might involve increased cortical stimulation by the limbic system. Since neuronal activity is tightly coupled to changes in cerebral blood flow and volume, the demonstration of increased cortical blood volume during playful versus routine motor and somatosensory activity would imply enhanced neuronal activity and provide insight into the complex interaction between play and learning. Near-infrared spectroscopy was used to detect changes in cortical blood volume during performance of (1) rudimentary visual, motor, and speech tasks; (2) integration of the tasks in a familiar routine manner; and (3) integration of the tasks in a novel, spontaneous, playful manner. No significant differences in cortical blood volume were found during the performance of the individual rudimentary tasks and their routine integration. However, the novel integration activity was associated with a significantly greater increase in frontal lobe oxyhemoglobin, deoxyhemoglobin, and total hemoglobin, as well as parietal lobe total hemoglobin. This small pilot study provides a limited measure of physiologic support for a relationship between play and learning. (J Child Neurol 2005;20:817—821).

Factors Associated With Lumbar Puncture Success: In Reply

In Reply .— We thank Drs Molina and Fons for their interest in our article on resident success of lumbar puncture (LP) and for sharing their data regarding the width of the intravertebral space of infants in the sitting versus the supine position. Their ultrasound results may influence the common debate of sitting versus recumbent position. Position did not remain in our model for efficacy …