Neonatal heelstick blood culture.

A new micro-heelstick blood culture technique was evaluated in 40 neonates who were believed to be clinically septic. Heelstick cultures were positive in 11 and peripheral venous cultures were positive in eight. All eight venous cultures had positive heelstick cultures. Heelstick blood cultures seem to be at least as sensitive as venous cultures.

Symptomatic arteriovenous malformation in infants less than 6 months of age.

The symptomatology and sequelae of symptomatic system arteriovenous (A-V) malformations in children less than 6 months old make an early diagnosis possible and early treatment mandatory. A group of 156 infants with systemic A-V malformations involving the CNS (81 infants), liver (61 infants), and lungs (14 infants) were studied to compare symptoms, diagnosis, treatment, and outcome. Congestive heart failure was present in 67% of the patients with CNS A-V malformations. Mortality among the patients with CNS A-V fistulas was 64%. Of those patients with hepatic A-V malformations 67% had abdominal masses, 48% congestive heart failure, and 55% died. Pulmonary A-V malformations presented with congestive heart failure 57%, cyanosis 43%, and resulted in a 43% mortality. Early combined medical and surgical therapy offered the best chance for a successful outcome.

Lumbar punctures and meningitis.

Four patients, with an additional seven from the literature, had meningitis following a lumbar puncture (LP) that disclosed normal cerebrospinal fluid (CSF). Animal studies demonstrate that perforation of the meninges in the presence of bacteremia enhances the development of meningitis. Simultaneous blood culture should be obtained with all LPs. Regardless of the results of the initial LP, a second CSF examination is recommended in any patient whose clinical condition is deteriorating. If the initial blood culture is positive, a second LP should be strongly considered in all newborn and very young infants.

Effect of resuscitative fluids upon physical properties of blood perfusing the brain.

Acute physiologic changes induced by the infusion of resuscitative fluids may be harmful, resulting in the clinical sequelae of pulmonary and intraventricular hemorrhage. Using a chronically catheterized lamb model, changes in plasma sodium concentration, osmolality, hematocrit, glucose, colloid osmotic pressure, and arterial pressure were quantified in blood directly perfusing the brain, following distal infusions of fluids commonly used during neonatal resuscitation: molar and .5M NaHCO3, D10W and D25W, and whole blood. Distal infusion of hypertonic solutions resulted in acute alterations in electrolyte and osmotic equilibrium in the common carotid artery. All infused solutions caused a brief elevation in mean blood pressure; whole blood transfusion resulted in a sustained increase in blood pressure.

Cerebral vascular response to hemorrhagic hypotension in newborn lambs: the influence of developing anemia.

The ability of newborn animals to autoregulate cerebral blood flow (CBF) has been documented. Most studies of the cerebral vascular response to hypotension utilize hemorrhage, generally confounded with anemia. We studied the cerebral blood flow and metabolic response of chloralose and urethane anesthetized newborn lambs to regulated hypotension. Lambs (< or = 7 days old) were catheterized for radioactive microsphere determinations of CBF. The dorsal sagittal sinus was catheterized to obtain cerebral blood samples for the calculation of oxygen uptake. Cerebral perfusion pressure was reduced in a step-wise fashion with hemorrhagic hypotension. Animals spontaneously became anemic with hypotension (AH; n = 8). In a group of animals (NH; n = 6), anemia was prevented by infusion of autologous red blood cells. Arterial pressure was reduced from control to 50, 40, and 30 mm Hg. In the AH group hematocrit fell 37% but was not different from control in the NH group. Total CBF was maintained in all groups. The lowest perfusion pressures studied were 25 +/- 1 and 22 +/- 1 mm Hg in AH and NH groups respectively. Oxygen delivery decreased (37%) only in the AH group, secondary to anemia. Calculated oxygen consumption was maintained in the AH group but increased (approximately 50%) in the NH group at 50 and 40 mm Hg. The ratio of oxygen uptake to oxygen delivery (fractional oxygen extraction) increased linearly in both groups as arterial pressure decreased. The major findings of these experiments are (i) The anesthetized newborn lamb can maintain CBF when perfusion pressure falls to 25 mm Hg and this autoregulatory capacity (classically defined) is not dependent on a change in hematocrit and, presumably, viscosity; (ii) Cerebral hypotension, anemic or not, appears to be accompanied by an increase in fractional extraction of oxygen.

A national survey concerning the ethical aspects of informed consent and role of medical students.

The authors surveyed a national random sample of medical students (10 percent of the graduating class of 1985) to identify the ways in which the students obtained informed consent from their patients and to learn the students' views of certain issues concerning informed consent. The results showed that the students introduced themselves to patients using methods that the authors grouped by levels of forthrightness. Those students who introduced themselves as medical students differed in their views on selected informed consent issues from students who introduced themselves as physicians. In general, all the students were less forthright about their status when given the opportunity to perform invasive procedures. Student gender, type of patient, and type of hospital were statistically associated with the students' behavior, according to bivariate analysis. After multivariate regression analysis, however, only the actions of the students' role models (residents and attending physicians) remained significantly associated with the students' behavior. The authors conclude that because some aspects of student behavior are at odds with the requirements of informed consent, medical educators must scrutinize the ethical dimensions of the policies they establish.

Pelvic examinations by medical students.

Involvement in patient care plays a critical role in medical education. Patients, however, have a right to refuse to participate in educational programs, and in the area of gynecologic care this takes on heightened sensitivity. Although the majority of clinical departments specifically inform patients of the student role, a substantial proportion do not have policies that adhere strictly to informed-consent guidelines.

Providing pediatric subspecialty care: A workforce analysis. AAP Committee on Pediatric Workforce Subcommittee on Subspecialty Workforce.

OBJECTIVE: To provide a snapshot of pediatric subspecialty practice, examine issues pertaining to the subspecialty workforce, and analyze subspecialists' perspective on the health care market. BACKGROUND: Before the effort of the Future of Pediatric Education II (FOPE II) Project, very little information existed regarding the characteristics of the pediatric subspecialty workforce. This need was addressed through a comprehensive initiative involving cooperation between subspecialty sections of the American Academy of Pediatrics and other specialty societies. METHODS: Questionnaires were sent to all individuals, identified through exhaustive searches, who practiced in 17 pediatric medical and surgical subspecialty areas in 1997 and 1998. The survey elicited information about education and practice issues, including main practice setting, major professional activity, referrals, perceived competition, and local workforce requirements. The number of respondents used in the analyses ranged from 120 (plastic surgery) to 2034 (neonatology). In total, responses from 10 010 pediatric subspecialists were analyzed. RESULTS: For 13 of the subspecialties, a medical school setting was specified by the largest number of respondents within each subspecialty as their main employment site. Direct patient care was the major professional activity of the majority of respondents in all the subspecialties, with the exception of infectious diseases. Large numbers of subspecialists reported increases in the complexity of referral cases, ranging between 20% (cardiology) and 44% (critical care), with an average of 33% across the entire sample. In all subspecialties, a majority of respondents indicated that they faced competition for services in their area (range: 55%-90%; 71% across the entire sample); yet in none of the subspecialties did a majority report that they had modified their practice as a result of competition. In 15 of the 17 subspecialties, a majority stated that there would be no need in their community over the next 3 to 5 years for additional pediatric subspecialists in their discipline. Across the entire sample, 42% of respondents indicated that they or their employer would not be hiring additional, nonreplacement pediatric subspecialists in their field in the next 3 to 5 years (range: 20%-63%). CONCLUSION: This survey provides the first comprehensive analysis to date on how market forces are perceived to be affecting physicians in the pediatric subspecialty workforce. The data indicate that pediatric subspecialists in most areas are facing strong competitive pressures in the market, and that the market's ability to support additional subspecialists in many areas may be diminishing.

Informed consent policies governing medical students' interactions with patients.

When medical students become involved in patient care, concerns are raised that have ethical and possibly legal implications. In order to determine compliance with the guidelines of the U.S. government and the Joint Committee on Accreditation of Hospitals pertaining to informed consent, the authors conducted a study of hospital administrators, medical school department chairpersons, and medical school deans (with response rates ranging from 82.3 to 95.1 percent) concerning policies on student involvement in patient care. The results show that only 37.5 percent of all responding teaching hospitals specifically informed patients that students would be involved in care. Only 51 percent of the responding medical schools that specifically gave their students instruction or guidance on initial patient interaction as a matter of policy insisted that their students introduce themselves as students and clarify their role in patient care. The authors conclude that medical educators' compliance with the ethical requirements of informed consent is incomplete.