Drawing clocks and driving cars.

OBJECTIVE: 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.

Clinical efficacy of racemic albuterol versus levalbuterol for the treatment of acute pediatric asthma.

STUDY OBJECTIVE: An efficacy treatment study is conducted comparing levalbuterol to racemic albuterol for acute pediatric asthma in the emergency department (ED). METHODS: This was a prospective, double-blind, randomized, controlled study involving 129 children (2 to 14 years), presenting to a pediatric ED with an acute moderate or severe asthma exacerbation. Children were treated using a standard ED asthma pathway. Primary outcomes were changes from baseline in clinical asthma score and the percentage of predicted forced expiratory volume in 1 second after the first, third, and fifth treatment. Secondary outcomes included number of treatments, length of ED care, rate of hospitalization, and changes in pulse rate, respiratory rate, and oxygen saturation. Occurrence of adverse events was recorded. RESULTS: Sixty-four children in the racemic albuterol and 65 children in the levalbuterol group completed the study. There were no differences between groups in primary outcomes, secondary outcomes, or adverse events. CONCLUSION: There was no difference in clinical improvement in children with acute moderate to severe asthma exacerbations treated with either racemic albuterol or levalbuterol.

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.

Prospective longitudinal comparative study of health-related quality of life in patients undergoing invasive treatments for localized prostate cancer.

BACKGROUND AND PURPOSE: Health-related quality of life (QoL) concerns are important for patients selecting treatment options for clinically localized prostate cancer and are critical in evaluating outcomes. We report pretreatment and post-treatment general and disease-specific QoL for the following invasive interventions: open radical prostatectomy (ORP), laparoscopic radical prostatectomy (LRP), and palladium-103 ((103)Pd) brachytherapy. PATIENTS AND METHODS: We performed a prospective longitudinal survey of 452 patients with newly diagnosed prostate cancer treated at a single medical center between 2001 and 2003. An Institutional Review Board-approved questionnaire comprised of validated QoL instruments was sent to patients scheduled to undergo ORP (N = 186), LRP (N = 116), or brachytherapy (N = 150). The same questionnaire was sent out 1, 3, 6, 9, and 12 months after therapy. Comparisons were made between the groups to determine if the choice of therapy resulted in differences in QoL. RESULTS: General QoL scores were minimally affected by the choices; however, the disease-specific domains of bowel, urinary, and sexual function were adversely affected by all modalities. The ORP and LRP groups were similar among disease-specific domains and received lower post-treatment urinary and sexual scores than the (103)Pd patients. At 12 months, 38% of ORP and 46% of LRP patients had returned to baseline urinary function compared with 75% of (103)Pd patients. At 12 months, 63% of (103)Pd patients had returned to baseline sexual function compared with 19% of both the LRP and ORP patients. CONCLUSIONS: Invasive treatments for localized prostate cancer have little impact on general QoL but significantly affect disease-specific domains. Both ORP and LRP have a greater initial negative impact on urinary and sexual function than (103)Pd. The differences among the treatments with regard to QoL provide information to patients faced with choosing a treatment.

Self-rated driving performance among elderly drivers referred for driving evaluation.

PURPOSE: To explore whether elderly drivers of varying driving skill levels (1) differ in their perception of their driving evaluation performance and (2) determine if self-rated driving evaluation performance is related to cognitive ability. METHODS: One hundred and fifty-two drivers aged 65 years or older and referred for a driving evaluation were enrolled into the study. Subjects were asked the question, "how well do you think you will perform today on your driving evaluation compared to others your own age?" Subjects also completed the Mini-Mental State Exam and a 30-min drive on a STISIM Drivetrade mark simulation (Systems Technology, Inc., Hawthorne, CA). Only 47 subjects completed both the simulated drive and self-rated item. RESULTS: Sixty-five percent of drivers rated themselves as performing better on a driving test than others of their age. Another 31.9% felt they would perform the same as others of their age on a driving test. A 50.0% of those considering themselves "a little better" and 52.9% of those considering themselves "a lot better" had an unsafe driving performance. As self-rated driving evaluation performance increased, there was a significantly increased risk of unsafe driving (p=0.02) in the study population. Drivers who considered themselves at least a little better than others of their age were over four times more likely to be unsafe drivers compared to others who believed they were comparable to or worse than other drivers of their age (RR=4.13, 95% CI=1.08-15.78). There was no significant difference in MMSE between self-rating groups (p=0.76). CONCLUSION: Older drivers assign high ratings to their driving performance, even in the presence of suspected skill decline. Cognitive ability was not related to self-rated driving evaluation performance.

Utility of the serum C-reactive protein for detection of occult bacterial infection in children.

OBJECTIVE: To assess the utility of serum C-reactive protein (CRP) as a screen for occult bacterial infection in children. METHODS: Febrile children ages 3 to 36 months who visited an urban children's hospital emergency department and received a complete blood cell count and blood culture as part of their evaluation were prospectively enrolled from February 2, 2000, through May 30, 2001. Informed consent was obtained for the withdrawal of an additional 1-mL aliquot of blood for use in CRP evaluation. Logistic regression and receiver operator characteristic (ROC) curves were modeled for each predictor to identify optimal test values, and were compared using likelihood ratio tests. RESULTS: Two hundred fifty-six patients were included in the analysis, with a median age of 15.3 months (range, 3.1-35.2 months) and median temperature at triage 40.0 degrees C (range, 39.0 degrees C-41.3 degrees C). Twenty-nine (11.3%) cases of occult bacterial infection (OBI) were identified, including 17 cases of pneumonia, 9 cases of urinary tract infection, and 3 cases of bacteremia. The median white blood cell count in this data set was 12.9 x 10(3)/ micro L [corrected] (range, 3.6-39.1 x10(3)/ micro L) [corrected], the median absolute neutrophil count (ANC) was 7.12 x 10(3)/L [corrected] (range, 0.56-28.16 x10(3)/L) [corrected], and the median CRP level was 1.7 mg/dL (range, 0.2-43.3 mg/dL). The optimal cut-off point for CRP in this data set (4.4 mg/dL) achieved a sensitivity of 63% and a specificity of 81% for detection of OBI in this population. Comparing models using cut-off values from individual laboratory predictors (ANC, white blood cell count, and CRP) that maximized sensitivity and specificity revealed that a model using an ANC of 10.6 x10(3)/L [corrected] (sensitivity, 69%; specificity, 79%) was the best predictive model. Adding CRP to the model insignificantly increased sensitivity to 79%, while significantly decreasing specificity to 50%. Active monitoring of emergency department blood cultures drawn during the study period from children between 3 and 36 months of age showed an overall bacteremia rate of 1.1% during this period. CONCLUSIONS: An ANC cut-off point of 10.6 x10(3)/L [corrected] offers the best predictive model for detection of occult bacterial infection using a single test. The addition of CRP to ANC adds little diagnostic utility. Furthermore, the lowered incidence of occult bacteremia in our population supports a decrease in the use of diagnostic screening in this population.

Analysis of perpetrator admissions to inflicted traumatic brain injury in children.

BACKGROUND: Scientific and courtroom debate exists regarding the timing of onset of symptoms and the mechanism of injury in infants and children with inflicted traumatic brain injury (ITBI). OBJECTIVES: To determine the time interval between ITBI and the onset of symptoms and to explore the mechanism of ITBI. DESIGN, SETTING, AND PATIENTS: Retrospective review of all cases of pediatric ITBI admitted between January 1, 1981, and July 31, 2001, to a large academic medical center and cases admitted to 2 additional academic institutions between January 1, 1996, and August 31, 2000, and January 1, 2001, and July 31, 2001, comparing 81 cases of ITBI in which perpetrators admitted to abuse with 90 cases in which no abuse admission was made. The patients with perpetrator admissions to ITBI consisted of 53 boys (65%) and 28 girls (35%). Their ages ranged from 2 weeks to 52 months. MAIN OUTCOME MEASURES: Characteristics associated with perpetrator admissions to ITBI in children. RESULTS: Shaking was the most common mechanism of injury among all cases with perpetrator admissions: 55 (68%) of the 81 perpetrators admitted to shaking the children. Impact was not described in 44 (54%) of the 81 cases. In cases in which only impact was described, 60% (12/20) of the children showed skull or scalp injury, compared with 12% (4/32) with skull or scalp injury in the shake only group. In 52 (91%) of 57 cases in which the time to the onset of symptoms was described, symptoms appeared immediately after the abuse. In 5 cases (9%), the timing of symptoms was less clear, but they occurred within 24 hours. None of the children were described as behaving normally after the event. CONCLUSIONS: The symptoms of inflicted head injury in children are immediate. Most perpetrators admitted to shaking without impact. These data, combined with the relative lack of skull and scalp injury, suggest that shaking alone can produce the symptoms seen in children with ITBI.

Incidence of and risk factors for additional tympanostomy tube insertion in children.

OBJECTIVE: To determine the incidence and risk factors that account for additional tympanostomy tube placement among children who have undergone an initial placement of ventilation tubes. DESIGN: Retrospective case review of consecutive patients. SETTING: A tertiary care pediatric hospital. PATIENTS: Five-year consecutive series of 2121 children cared for in a hospital-based, tertiary care pediatric otolaryngology practice. INTERVENTION: Subsequent need for additional ventilation tube surgery. RESULTS: Four hundred twenty-three (19.9%) of the 2121 children who underwent initial placement of bilateral myringotomy tubes (BMTs) between April 20, 1995, and May 25, 1998, subsequently had a second set of tubes placed by May 25, 2000. Children 18 months or younger at the time of initial BMT placement were nearly twice as likely (26.3% vs 15.9%) to undergo a second BMT procedure when compared with children who were older than 18 months at initial surgery (P<.005). The probability of having a second BMT procedure was reduced if adenoidectomy was performed at the first BMT procedure (0.08 vs 0.24, P<.001). Adenoidectomy status, craniofacial deformities, and a family history of adenoidectomy or tonsillectomy with or without BMTs were independent risk factors for multiple BMTs. CONCLUSIONS: Epidemiologic analysis of this consecutive series of patients who underwent BMT placement in a tertiary care pediatric otolaryngology practice suggests that 1 in 5 patients will subsequently require a second set of ventilation tubes. Age younger than 18 months at the time of the initial BMT procedure is associated with an increased risk for additional surgery but is not an independent risk factor. Adenoidectomy reduces the incidence of subsequent BMTs following initial surgery.

American Society of Pediatric Otolaryngology members' experience with recurrent respiratory papillomatosis and the use of adjuvant therapy.

OBJECTIVE: To evaluate how evolving treatment technologies have affected our management of recurrent respiratory papilloma (RRP) since the last comprehensive survey of pediatric otolaryngologists in 1998. DESIGN: Web-based survey of all American Society of Pediatric Otolaryngology members residing in the United States, Canada, Europe, and Australia. RESULTS: Evaluable survey results were tabulated from 74 practitioners in 62 separate practices managing 700 current children with RRP. A total of 150 (21%) of these patients presently receive adjuvant medical therapies with cidofovir and interferon, accounting for more than two thirds of the total. Sixty-one percent of patients treated with cidofovir have experienced a beneficial response. Distal spread of RRP has occurred in 94 (13%) of the 700 patients. Half of the practices surveyed have experienced a death from RRP, with 89% of deaths directly related to RRP. The laryngeal microdebrider (53%) has supplanted the carbon dioxide laser (42%) as the preferred means of surgically removing papilloma from the larynx in children. Spontaneous, apneic, and jet ventilation (88%) anesthesia techniques have replaced the use of laser-safe endotracheal tubes (10%) as the preferred anesthetic management. Routine human papillomavirus subtyping is practiced by 45% of respondents while 15% treat all their patients with antireflux medications. Half of respondents send lesions for histologic examination only if there is a change in growth pattern while one third send lesions with every surgery. CONCLUSIONS: Recurrent respiratory papilloma continues to be a frustrating disease to treat and is associated with significant morbidity and mortality. There has been an evolution in the past decade toward the increased use of antiviral adjuvant therapy and the use of microdebrider techniques for surgical management.

Anesthetic complications of tympanostomy tube placement in children.

OBJECTIVE: To determine the incidence of perioperative anesthesia complications during bilateral myringotomy with tympanostomy tube placement (BMTT). SETTING: Tertiary care children's hospital where otolaryngology attending physicians and residents performed surgical procedures. Anesthesia providers included pediatric anesthesiologists, residents, nurse anesthetists, and students. METHODS: Medical record review was performed for a consecutive series of 3198 children undergoing BMTT (1000 prospectively, 2198 retrospectively). For the prospectively studied patients, major adverse events, which included laryngospasm and stridor, and minor adverse events, including upper airway obstruction, prolonged recovery, emesis, and persistent postprocedural agitation, were noted. Also recorded were the patient's American Society of Anesthesiologists (ASA) physical class status, age, concurrent medical conditions, and type of anesthesia provider. RESULTS: Fewer than 9% of prospectively studied pediatric patients experienced a minor adverse event, whereas a major event occurred in 1.9%. Eighty-one percent of the events experienced were attributable to agitation or prolonged recovery. Neither ASA status (P =.38), age (P =.15), nor type of anesthesia provider (P =.06) were significantly related to the occurrence of an adverse event. However, a child with an acute or chronic illness has 2.78 times the odds of experiencing an adverse event compared with a child with no illness (P<.001). CONCLUSIONS: Anesthesia administered for placement of tympanostomy tubes by physicians who specialize in the care of children in a tertiary care children's hospital is safe. The most significant predictor of a minor anesthetic event during BMTT is the presence of a preexisting medical condition or concurrent acute illness.

Indices of hemodynamic and respiratory functions in premature infants at risk for the development of cerebral white matter injury.

OBJECTIVE: To examine potential differences in clinical risk factors, including indices of hemodynamic and respiratory functions, of premature infants developing periventricular hemorrhagic infarction (PHI) or periventricular leukomalacia (PVL). STUDY DESIGN: Indices of hemodynamic stability and respiratory function were measured prospectively during the first week of life in a cohort of 100 premature infants with respiratory distress. Maternal history was retrospectively reviewed. These data were correlated with cranial ultrasonography using one-way ANOVA, Bonferroni multiple comparisons, and Wilcoxon rank sum tests. Longitudinal analysis was performed using Generalized Estimating Equations. RESULTS: Fifty-two infants with normal cranial ultrasound studies were compared to 12 with PHI and 9 with PVL. Infants developing PHI had significantly lower birth weights, lower Apgar scores, were more often male and multiple gestations, and required more vasopressor support than infants with normal ultrasound studies. Infants with PHI had significantly worse indices of respiratory function than either normal infants or those with PVL. PVL was significantly associated with maternal chorioamnionitis, whereas PHI was not. CONCLUSION: These data suggest that there are important differences in the pathogenesis of PHI and PVL. A clear understanding of these differences is required before future preventive strategies can be formulated.

Analysis of a staging assessment system for prediction of surgical interval in recurrent respiratory papillomatosis.

INTRODUCTION: A staging system for assessment of recurrent respiratory papillomatosis (RRP) has been in use over the last 3 years for 17 patients at our children's hospital. OBJECTIVE: To evaluate a staging system for assessment of RRP on the basis of the predictive value on the surgical interval of: anatomic staging system score, urgency of intervention, voice quality, and stridor. To assess effect on surgical interval of the age of patient at time of surgery and use of adjuvant therapy. To develop a model based on the staging criteria to predict need for adjuvant therapy. DESIGN: Validation cohort. SETTING: Academic children's hospital. RESULTS: Estimated time to surgery decreased by "x days": "independent variable" "(95% CI)" as follows. Four days: each 1 point in total anatomical score (0.2, 8); 120 days: total anatomical score >20 (37,203); 143 days: urgent versus scheduled surgery (42, 243); 100 days: aphonic versus normal voice (-211, 343); 31 days: abnormal versus normal voice (-281, 343); 125 days: stridor at rest versus no stridor (-31, 281); 109 days: stridor with activity versus no stridor (19, 198); 26 days: each 1 year decrease in age (22, 30). Adjuvant therapy delays next surgery by 32 days (-4, 69) and average scores decreased while on adjuvant therapy. CONCLUSIONS: Elements of our proposed staging system are effective in prediction of surgical interval with statistical significance achieved for total anatomical scores, urgency of intervention and stridor with activity versus no stridor. This study is pilot in nature and provides a framework upon which future studies can be based. The analysis of a larger, more severity diverse population could yield results which lead to a model capable of effectively predicting future surgical interval based on a weighted prediction score calculated from age, comorbidities, anatomic staging score, and clinical staging score.

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 patient's 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.

Evaluation of a lactation support service in a children's hospital neonatal intensive care unit.

Breastfeeding hospitalized infants can be difficult. The authors assessed the effectiveness of an International Board Certified Lactation Consultants (IBCLC) service to increase the proportion of infants given their own mother's milk (OMM) in a children's hospital neonatal intensive care unit (NICU). The charts of 350 randomly selected patients admitted the year before and after implementation of the service in July 1997 were abstracted. Factors significantly associated with infants being given OMM included infant sex, ethnicity, length of NICU stay, and 5-minute Apgar score. After comparison of the periods before and after program implementation, the proportion of NICU infants ever given their OMM was found to have increased from 31% to 47% (P = .002). This increase differed significantly in relation to infants' clinical status and/or management (5-minute Apgar score, length of NICU stay, and age at NICU admission) but not in relation to maternal factors. Mothers with infants in the NICU should have access to lactation counseling.

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.

Predicting nursing home placement among home- and community-based services program participants.

BACKGROUND: Several states offer publicly funded-care management programs to prevent long-term care placement of high-risk Medicaid beneficiaries. Understanding participant risk factors and services that may prevent long-term care placement can facilitate efficient allocation of program resources. OBJECTIVES: To develop a practical prediction model to identify participants in a home- and community-based services program who are at highest risk for long-term nursing home placement, and to examine participant-level and program-level predictors of nursing home placement. STUDY DESIGN: In a retrospective observational study, we used deidentified data for participants in the Connecticut Home Care Program for Elders who completed an annual assessment survey between 2005 and 2010. METHODS: We analyzed data on patient characteristics, use of program services, and short-term facility admissions in the previous year. We used logistic regression models with random effects to predict nursing home placement. The main outcome measures were long-term nursing home placement within 180 days or 1 year of assessment. RESULTS: Among 10,975 study participants, 1249 (11.4%) had nursing home placement within 1 year of annual assessment. Risk factors included Alzheimer's disease (odds ratio [OR], 1.30; 95% CI, 1.18-1.43), money management dependency (OR, 1.33; 95% CI, 1.18-1.51), living alone (OR, 1.53; 95% CI, 1.31-1.80), and number of prior short-term skilled nursing facility stays (OR, 1.46; 95% CI, 1.31-1.62). Use of a personal care assistance service was associated with 46% lower odds of nursing home placement. The model C statistic was 0.76 in the validation cohort. CONCLUSIONS: A model using information from a home- and community-based service program had strong discrimination to predict risk of long-term nursing home placement and can be used to identify high-risk participants for targeted interventions.

Safety of outpatient surgery for obstructive sleep apnea.

OBJECTIVE: Determine the safety experience of adult obstructive sleep apnea patients undergoing airway surgery. STUDY DESIGN: A retrospective cohort study. SETTING: The experience of members of a large Medicaid managed care organization between January 10, 2009, and June 30, 2011. SUBJECTS AND METHODS: Four hundred fifty-two adult Medicaid obstructive sleep apnea (OSA) patients (404 ambulatory, 48 inpatient) receiving head and neck airway surgery form the basis of this report. Four safety indicators were reported from administrative data for 30 days: emergency room visit, inpatient admission, observation day, and 3 or more primary care physician visits. The occurrence of myocardial infarction, deep venous thrombosis, stroke, pulmonary embolism, tracheostomy, or transfusion was noted. RESULTS: Ninety-four percent of the nasal, 86% of the palatal, and 79% of the nasal/palatal surgeries (89% overall) were ambulatory. The observed catastrophic complication rate among ambulatory patients was zero (95% confidence interval, 0.0%-1.1%). Emergency room visits for pain-related diagnoses were the most common adverse outcome (51%). Administrative data sets can be used to provide insight into practice safety questions. CONCLUSION: Contrary to guidelines, most OSA patients underwent ambulatory head and neck airway surgery. The observed catastrophic complication rate was zero. Administrative data sets can be used to provide insight into practice safety questions. Further study is warranted of ambulatory surgery management of adult sleep apnea patients.

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.

Proinflammatory cytokine-receptor interaction model improves the predictability of cerebral white matter injury in preterm infants.

Proinflammatory cytokines have been variably linked to development of cerebral white matter injury (WMI) in preterm infants. Because soluble receptors tightly control cytokine bioactivity, we modeled cytokine-receptor interaction as a predictor of WMI. Plasma from 100 preterm infants was assayed for cytokines (tumor necrosis factor alpha, interleukin (IL-1beta, IL-6) and their soluble receptors (sTNF-RI), sTNF-RII, sIL-1RA, and sIL-6R). Cranial ultrasound (US) results were correlated with cytokine and receptor concentrations individually and with cytokine-receptor interaction models (PROC LOGISTIC; SAS Software). Receiver operating characteristic curves were constructed to determine the predictability of WMI. Fifty-two infants with normal US exams were compared with 21 infants with evidence of WMI. There was no association between individual cytokine or receptor concentrations and the development of WMI. However, modeling cytokines with their soluble receptors significantly improved the predictability of WMI. We concluded that consideration of cytokine-receptor interaction may be more important than individual cytokine concentrations alone in determining the role of inflammation in the pathogenesis of WMI in preterm infants.

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 < or =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.