Regina O'Donnell

Communicating bad news: a pediatric department's evaluation of a simulated intervention.

Objective. To determine if pediatric residents and emergency department (ED) fellows could improve their ability to counsel and inform standardized patients (SPs) about bad news. Methodology. A crossover, self-controlled design in which trainees were their own control individuals, and SPs provided feedback after the first interview. The setting was the consultation room in the ED of a large childrens hospital. The outcome measures included examining the counseling and informing skills of study participants. Results. Trainees improved their informing skills after being provided feedback in the broad areas of communication and follow-up and in the total number of content areas asked. Their counseling skills improved in two areas: 1) promoting more trust and 2) making parents feel less dependent. Those trainees who scored higher on counseling skills discussed more total and critical content issues with SPs in the study. Trainee feedback revealed a very high rating of the educational process, and the trainees also felt much more confident about their skills after the first and second sessions. Conclusions. Using SPs to teach residents and ED fellows to give bad news is an effective educational process that provides trainees with interactions that simulate real-life experience

A feeding scale for research and clinical practice to assess mother—infant interactions in the first three years of life

The Feeding Scale provides a reliable rating of mother-infant/toddler interactions during a 20-minute feeding in a laboratory setting. The scale consists of 46 mother and infant behaviors, which are rated at the end of the feeding session. Observations of mother—infant interactions during two feedings separated by 2 weeks showed considerable stability. Five subscale scores are derived (1) Dyadic Reciprocity, (2) Dyadic Conflict, (3) Talk and Distraction, (4) Struggle for Control, and (5) Maternal Non-Contingency, Predictive validity of the Feeding Scale has been demonstrated and it discriminates between infants with and without feeding disorders as well as three diagnostic categories of feeding-disordered infants. The Feeding Scale can be used with infants and toddlers ranging in age from 1 month to 3 years.

Determination of Normal Ear Temperature with an Infrared Emission Detection Thermometer

STUDY OBJECTIVE To determine normal body temperature with an infrared emission detection ear thermometer. DESIGN Cross-sectional convenience sample. SETTING Four acute and long-term health care facilities. PARTICIPANTS Subjects who denied recent potentially febrile illness and ingestion of medications affecting normal body temperature. RESULTS Two thousand four hundred forty-seven subjects aged 12 hours to 103 years were enrolled. Ear temperatures were normally distributed for each of eight age groups. There were differences in mean temperature among different age groups (P < .001, by ANOVA) and a striking cutoff at adolescence; the mean temperature for children aged 3 days to 10 years was 36.78 +/- 0.47 degrees C, as compared to 36.51 +/- 0.46 degrees C for subjects 11 years and older (P < .001, by t test). Temperatures were higher in female subjects and showed the characteristic diurnal variation of normal body temperature in five subjects studied longitudinally. The reproducibility of the ear thermometer was better than that of a commonly used electronic thermometer at the oral and axillary sites. CONCLUSION The infrared emission detection ear thermometer is an accurate means of assessing normal body temperature without using corrective offsets to estimate temperature at other body sites. On the basis of these data, the 95th percentile for infrared emission detection temperature in children younger than 11 years old was 37.6 degrees C. The 99th percentile was 37.9 degrees C for children younger than 11 years old and 37.6 degrees C for people 11 years or older. Because only 1% of normal people have an infrared emission detection temperature higher than these values, these may represent appropriate cutoffs for fever screening using this device.

Prevalence of müllerian duct anomalies detected at ultrasound

The true prevalence of müllerian duct abnormalities is not well established. We used standard ultrasound examinations to establish the prevalence of müllerian duct abnormalities in girls and women who were evaluated for reasons unrelated to the presence of uterine anomalies. Prospective ultrasound examinations for nonobstetric indications in 2,065 consecutive girls and women (aged 8-93) showed that 8 had anomalies, including bicornuate uterus, septate uterus, and double uterus. In this first attempt to determine the prevalence of uterine anomalies in the general population, using noninvasive methodology, the rate of anomalies was 3.87 per 1,000 women (exact 95% confidence interval: 1.67-7.62), or approximately 1 in 250 women. This prevalence estimate may be greater than the true rate if selection biases are strong, or less than the true prevalence if ultrasound detection rates are low. As a first attempt to establish the prevalence by pelvic ultrasound in a consecutive series, these data may serve as a baseline estimate.

Obstetrical brachial plexus palsy (OBPP) outcome with conservative management

Resurgence of neurosurgical intervention of obstetrical brachial plexus palsy prompted our review of 186 patients evaluated between 1981 and 1993, correlating clinical examination, electrodiagnosis, and functional outcome with conservative management. Eighty‐eight percent had upper brachial plexus palsies, and 63% were mild. Forty‐two infants required no long‐term follow‐up because they rated 1 or 2 on initial physical examination. Comparing first and last follow‐up clinical findings of the remaining 149 patients, there was high agreement (correlation r = 0.81; P < 0.001). Pearson correlation of initial physical exam with electrodiagnosis at three intervals was relatively stable (r = 0.87, 0.88, 0.69). One hundred eight (72%) of the patients remained in their original severity groups. Thirty‐three of 41 patients with discrepant follow‐up scores improved by at least one category. Eight patients deteriorated. The natural pathophysiology and recovery of OBPP is presented.

Stabilization of Asthma Mortality

BACKGROUND Rates of death from asthma in the United States have increased since 1978. OBJECTIVE To identify and evaluate recent trends in asthma mortality. METHODS Analysis of data from the National Center for Health Statistics identifying asthma (ICD 493) as the underlying cause of death in the 50 United States and the District of Columbia with rates of death from asthma by age, race, and sex and age-adjusted rates of death by race. The Bureau of the Census provided population data by age, race, and sex that permitted calculation of rates of death at 5 through 34 years of age. The Departments of Health of Australia, Canada, Great Britain, and New Zealand provided numbers of deaths from asthma and population data from which we have calculated rates of death. RESULTS Rates of death from asthma in the United States increased from .8 per 100,000 general population in 1977 and 1978 to 2.0 in 1989 and have been 1.9 or 2.0 since then until an increase to 2.1 in 1994. A significant difference in regression over groups indicates a difference in average rates between 1979 through 1987 compared with 1988 through 1994. Rates of death from asthma have been much higher for white females than white males with an increasing disparity. Rates of death from asthma at 5 through 34 years of age have been much greater in blacks than whites with no significant change in rates across time from 1980 through 1994. Age-adjusted rates for blacks over all ages increased from 1.5 in 1977 and 1978 to 3.5 in 1988 with rates no higher than that until an increase to 3.7 in 1994. Age-adjusted rates for whites increased from .5 in 1977 to 1.2 by 1989 with none higher than that since then through 1994. Comparison of slopes indicates a significantly greater increase for blacks than whites (F = 68.296, P < .0001). Equality of slopes tests indicate significantly greater age-adjusted rates of increase for each race separately for 1979 through 1987 compared with 1988 through 1994. CONCLUSION Since 1988 rates of death from asthma in the United States for most ages have stabilized at rates more than 50% higher than those of 1979, but there has been only a suggestion of stabilization of rates at 5 through 34 years of age, ages at which certification of death as due to asthma is most accurate. Rates of death have been much higher for blacks than whites, and among whites rates have increased more for females than males. These differences might be due to difference in prevalence or severity of differences in accuracy of diagnosis. Improvements in management would reduce asthma mortality.

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.

Transcranial Doppler (TCD) screening for stroke prevention in sickle cell anemia: pitfalls in technique variation

Background. The Stroke Prevention Trial in Sickle Cell Anemia (STOP) identified children as being at high stroke risk if the time-averaged maximum mean velocity (TAMMV) of the middle cerebral or intracranial internal carotid arteries measured ≥ 200 cm/s. These values were obtained utilizing a 2-mHz dedicated nonimaging pulsed Doppler technique (TCD) and manual measurements. Questions have been raised as to the comparability of results obtained with different ultrasound machines and measurement techniques.¶Objective. The purpose of this study was to compare nonimaging (TCD) and transcranial duplex imaging (TCDI) findings in children potentially at risk for stroke with sickle cell disease.¶Materials and methods. Twenty-two children with sickle cell disease and no history of stroke were evaluated by both TCD and TCDI. Examinations were performed on the same day without knowledge of the other modality results and read independently using manually obtained measurements. Mean velocities, peak systolic velocities, and end diastolic velocities obtained by the two techniques were compared. In a subgroup, manual measurements were compared to electronically obtained measurements. ¶Results. TCDI values were lower than TCD measurements for all vessels. TCDI TAMMV values were most similar to the TCD values in the middle cerebral artery (–9.0 %) and distal internal cerebral artery (–10.8 %), with greater variability in the anterior cerebral artery (–19.3 %), bifurcation (–16.3 %), and basilar arteries (–23.1 %). Risk group placement based on middle cerebral artery TAMMV values did not change when comparing the two techniques. Measurements obtained electronically were lower than those obtained manually. ¶Conclusion. Velocities obtained by TCDI may be lower than TCD measurements, and these differences should be taken into consideration when performing screening for stroke risk and selection for prophylactic transfusion based on the STOP protocol.

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.

Counseling parents of a child dead on arrival: A survey of emergency departments☆☆☆

The purposes of this study were to (1) document whether or not responding emergency departments (EDs) have a process and/or team to interact with parents of children dead on arrival (DOA); (2) conduct a needs assessment to determine what information is essential to convey to a family of a child DOA; and (3) determine what EDs are doing to their residents/fellows in crisis counseling. A survey instrument was developed using input from key health care professionals at Childrens Hospital who are involved in the acute care of children and their families. This survey was sent to directors of EDs in all childrens hospitals and those general hospitals with more than 400 beds. Respondents identified themselves as ED directors at childrens hospitals or general hospitals throughout the United States. The survey documented the lack of a process or team approach to counseling the family of a child who presents DOA. Often, the most inexperienced physicians are expected to provide this information and to counsel parents. Few EDs reported offering communication skills training in this area. Many respondents expressed dissatisfaction about the lack of a process or team regarding patients who present DOA and recognize the need for improvement.