Evaluation of a pediatric hospitalist service: impact on length of stay and hospital charges.

OBJECTIVES: Inpatient medical services supervised by pediatric hospitalist physicians are a new development in academic medical centers in the United States. In a large pediatric teaching hospital, we compared length of stay, readmission rates, and hospital charges for children admitted to medical services with and without a hospitalist system of care. DESIGN: This retrospective observational study compared a baseline year of a traditional ward service (TS) with a subsequent year of a new hospitalist system of care called the Generalist Inpatient Service (GIS). Data were obtained from the hospital's clinical, demographic, and financial databases and from selected record review. All hospitalizations were at least 24 hours long and did not involve a stay in an intensive care unit. RESULTS: The average length of stay was longer for the 627 TS hospitalizations than for the 813 GIS hospitalizations (2.7 +/- 2.0 vs 2.4 +/- 1.7 days). Total hospital charges were significantly lower on the GIS ($3002 +/- $2160 vs $2720 +/- $1933) because of lower room and respiratory therapy charges. Three readmissions to the TS and 8 to the GIS occurred within 24 hours of hospital discharge and were, therefore, considered potentially preventable by a longer initial hospital stay. CONCLUSIONS: In a large pediatric teaching hospital, a system of inpatient care provided by hospitalists can reduce length of stay. This model has the potential to control hospital charges in a period of increasing health care costs.

Imaging of congenital anomalies of the temporal bone.

This article briefly presents the embryology of the ear and discusses the external auditory canal and middle ear, including first branchial cleft anomalies, external auditory canal atresia and stenoses, congenital cholesteatoma, and congenital teratoma. Topics related to the labyrinths include aplasia, the common-chamber anomaly, the pseudo-Mondini and Mondini malformations, semicircular canal dysplasia, and the large vestibular aqueduct. Vascular malformations and variations also are presented, including the absent and aberrant internal carotid artery, the persistent stapedial artery, and high jugular bulb; cerebrospinal fluid and perilymph fistulas are the subjects of the final section.

Higher triglycerides, lower high-density lipoprotein cholesterol, and higher systolic blood pressure in lipoprotein lipase-deficient heterozygotes. A preliminary report.

BACKGROUND: Heterozygous lipoprotein lipase (LPL) deficiency has been associated with familial hypertriglyceridemia and familial combined hyperlipidemia. Studies of heterozygotes with LPL gene defects at amino acid residues 188 and 207 showed higher triglycerides (TG) and lower HDL cholesterol (HDL-C), with no elevation in LDL cholesterol (LDL-C). Other LPL defects may reveal alternate clinical phenotypes. METHODS AND RESULTS: We evaluated three families with defects at amino acid residues 64, 194, and 188. Thirty-eight heterozygotes (8 with defect 64, 14 with defect 194, and 16 with defect 188) and 95 family members without defects were studied. Plasma lipid, lipoprotein, and apolipoprotein (apo) values were measured, as well as blood pressure. Pooled carriers demonstrated higher systolic blood pressure (SBP) (127 versus 116 mm Hg, P < .0001) and TG (160 versus 125 mg/dL, P = .004) and lower HDL-C (44 versus 52 mg/dL, P = .001) than did noncarriers. A comparison of the 188 carriers and noncarriers revealed the most striking phenotypic characteristics, with lower HDL-C (36 versus 51 mg/dL, P < .0001) and HDL-C/(apo A-I + apo A-II) (0.21 versus 0.24, P = .002) and higher TG (206 versus 123 mg/dL, P = .0003), SBP (132 versus 116 mm Hg, P = .0004), and apo B/LDL-C (1.12 versus 0.93, P < .0001). CONCLUSIONS: These data confirm past observations that LPL deficient heterozygotes trend toward lower HDL-C and higher TG levels while potentially expressing higher SBP. These data also implicate the specific LPL gene defect as a contributing factor to the variable expression of HDL-C, TG, and SBP.

Incentive spirometry to prevent acute pulmonary complications in sickle cell diseases.

BACKGROUND: This study was designed to determine the incidence of thoracic bone infarction in patients with sickle cell diseases who were hospitalized with acute chest or back pain above the diaphragm and to test the hypothesis that incentive spirometry can decrease the incidence of atelectasis and pulmonary infiltrates. METHODS: We conducted a prospective, randomized trial in 29 patients between 8 and 21 years of age with sickle cell diseases who had 38 episodes of acute chest or back pain above the diaphragm and were hospitalized. Each episode of pain was considered to be an independent event. At each hospitalization, patients with normal or unchanged chest radiographs on admission were randomly assigned to treatment with spirometry or to a control nonspirometry group. Each patient in the spirometry group took 10 maximal inspirations using an incentive spirometer every two hours between 8 a.m. and 10 p.m. and while awake during the night until the chest pain subsided. A second radiograph was obtained three or more days after admission, or sooner if clinically necessary, to determine the incidence of pulmonary complications. Bone scanning was performed no sooner than two days after hospital admission to determine the incidence of thoracic bone infarction. RESULTS: The incidence of thoracic bone infarction was 39.5 percent (15 of 38 hospitalizations). Pulmonary complications (atelectasis or infiltrates) developed during only 1 of 19 hospitalizations of patients assigned to the spirometry group, as compared with 8 of 19 hospitalizations of patients in the nonspirometry group (P = 0.019). Among patients with thoracic bone infarction, no pulmonary complications developed in those assigned to the spirometry group during a total of seven hospitalizations, whereas they developed during five of eight hospitalizations in the nonspirometry group (P = 0.025). CONCLUSIONS: Thoracic bone infarction is common in patients with sickle cell diseases who are hospitalized with acute chest pain. Incentive spirometry can prevent the pulmonary complications (atelectasis and infiltrates) associated with the acute chest syndrome in patients with sickle cell diseases who are hospitalized with chest or back pain above the diaphragm.

Primary hyperlipidemia in a pediatric population: classification and effect of dietary treatment.

Patients seen at a pediatric lipid clinic over a 27-month period were reviewed retrospectively to evaluate types of primary lipid disorders and effect of dietary treatment at the first follow-up visit. One hundred eighty-two patients were classified into one of four categories: (1) elevated low-density lipoprotein cholesterol (LDL-C) with LDL-C > 95th percentile (32%); (2) isolated triglyceride (TG)/high-density lipoprotein cholesterol (HDL-C) abnormalities, with TG > 95th percentile and/or HDL-C < 5th percentile (30%); (3) borderline LDL-C, TG, or HDL-C (29%); (4) normal (9%). The American Heart Association Step-One Diet was prescribed for all patients older than 2 years, and they received extensive nutritional and risk-management counseling. Of these patients, 59 (32%) returned for at least one follow-up visit and mean changes in lipid values between initial and first follow-up visits were evaluated. Levels of LDL-C decreased by 24 mg/dL in 22 patients with elevated LDL-C levels. Triglyceride levels decreased by a mean of 22 mg/dL and HDL-C increased by a mean of 4 mg/dL in 21 patients with isolated TG/HDL-C abnormalities. Levels of LDL-C tended to rise in this group, but not to a significant degree. A new finding of this report is that screening for total cholesterol results in the identification of many children with TG or HDL-C abnormalities alone and that the Step-One Diet appears to be effective in improving both TG and HDL-C levels in these patients.

Trp64----nonsense mutation in the lipoprotein lipase gene.

A lipoprotein lipase (LpL) gene defect has been identified, a G----A transition at nucleotide position 446 of exon 3, resulting in a premature termination codon (Trp----stop) at amino acid residue 64. This defect was identified in a Type I hyperlipoproteinemic subject with an amino acid residue 194 defect in the other allele. Plasma lipoprotein values as well as LpL mass and activity in postheparin plasma were determined in the subjects with the residue 64 defect and in other LpL-deficient heterozygotes. LpL mass levels in both the Type I and the other subject with a 64 LpL defect were markedly reduced. This may be explained by rapid degradation of LpL protein or decreased secretion from the 64 defective allele. Alternatively, the marked reduction or absence of mass associated with the 64 defect may be due to synthesis of a severely truncated protein which escapes immunologic detection.

How I teach medical students as an attending physician.

The General Professional Education of the Physician (GPEP) Report (1984) recommended a major re-examination of the clinical clerkship, so that medical students could master the basic skills of medicine before graduation. These include clinical observation, interviewing, physical examination, and problem-solving skills. This essay discusses the teaching approach of one attending physician during the third year ward clerkship in pediatrics. It describes how many of the goals of clinical medical education can be accomplished during the clerkship in a practical, realistic way. It is the only description about what happens during the teaching sessions of a clinical clerkship on a day by day basis in the medical literature. This approach may serve as a model for clinical teachers of medicine in the organization and planning of the clerkship experience.

The evaluation of ear canal, middle ear, temporal bone, and cerebellopontine angle masses in infants, children, and adolescents.

Ear canal, middle ear, temporal bone, and CPA angle masses (except for cholesteatomas) are rare in the pediatric population. The physician needs to have a high degree of suspicion for such lesions if a child presents with ear pain unrelated to infection or otorrhea that fails to improve after treatment. A precise diagnosis needs to be made in these children and also in those with hearing loss, vertigo, and facial paralysis. The most useful imaging procedures for ear, temporal bone, and CPA masses are CT and MR imaging. With a suspected vascular lesion, a definitive diagnosis usually can be made by an imaging procedure or angiography. In all cases of mass lesions, except for some aneurysms and infections, a tissue diagnosis must be secured.

Severity of disease correlated with fever reduction in febrile infants.

A prospective study of the effects of fever reduction on the clinical appearance of infants at risk for occult bacteremia was undertaken to study the hypothesis that infants with bacteremic illness fail to improve clinically following defervescence compared with infants with benign viral illness. A total of 154 children were enrolled in the study, including 19 with bacteremia: 13 with occult Streptococcus pneumoniae bacteremia, two with occult Haemophilus influenzae, type b bacteremia, and four with Haemophilus meningitis and bacteremia. There were no differences in degree of temperature reduction with acetaminophen between the bacteremic and nonbacteremic groups of infants. Among infants with bacteremia but without meningitis, differences from nonbacteremic children were detected in clinical appearance prior to fever reduction but not following defervescence. All patients with meningitis appeared seriously ill before and after defervescence. It was concluded that clinical improvement with defervescence is not a reliable indicator of the presence of occult bacteremia. Lack of clinical improvement with defervescence may be a reliable indicator for the presence of meningitis. Because there were differences in clinical appearance prior to fever reduction, routine administration of acetaminophen may interfere with the clinical evaluation by the physician.