Drinking patterns and social consequences: a study of middle-class adolescents in two private pediatric practices.

One hundred sixty-two adolescents who were seen at two suburban private pediatric practices completed an anonymous, written questionnaire about drinking and drug habits. The respondents' ages ranged from 14 to 17 years; all were white and from middle- or upper middle-class families. The adolescents reported high self-esteem, good general health, and few psychologic problems. The majority (63%) reported having drunk alcohol at some time, and the proportion who professed never to drink alcohol became progressively smaller with age, to only 15% at age 17 years. Overall, one fifth claimed that they had to drink more than six beers before they "got a buzz," and this proportion increased to 43% by age 17 years. Among the 17-year-old respondents, 40% replied that their good friends had used alcohol more than 50 times. Twenty-four percent of respondents said that a good friend had received a citation for driving while intoxicated. Almost one fifth of respondents stated that someone in their family drinks alcohol every day, and that someone close to them has a drinking problem. Social acceptance of drinking, peer pressure, and the ready availability of alcohol have led to an epidemic of alcohol use among teenagers and to social, academic, and health problems in many frequent users. Pediatricians should play a more active role in the identification and management of alcohol abuse by their adolescent patients.

Human immunodeficiency virus infection in urban adolescents: can we predict who is at risk?

Few studies have evaluated the extent of human immunodeficiency virus (HIV) in the adolescent population. However, there has been growing concern that sexual and drug experimentation common in this age group may increase their risks of transmitting the virus. Between October 1, 1987, and January 31, 1989, a blinded, unlinked HIV seroprevalence study was conducted among all adolescents aged 13 through 19 receiving ambulatory care at Children's National Medical Center and having blood drawn for other routine medical indications. Overall, seroprevalence in this group of patients was 0.37% (3.7/1000), with the highest prevalence in females (4.7/1000) and patients 18 through 19 years of age (5.6/1000). Of adolescents considered at high risk who were offered and accepted voluntary HIV testing during the same time period, 4.1% (41/1000) were positive. Inasmuch as this represents only 38% of all of the positive tests obtained in the blinded testing phase of the study, it may indicate that a substantial proportion of HIV-positive adolescent patients may be missed by using standard criteria and methods of identifying risk and/or that those most at risk may be reluctant to be tested for HIV infection. The results suggest that HIV infection is present in this population of urban adolescents and that the seroprevalence rate is higher than in other nonselect groups. Moreover, using traditional risk factors as screening criteria may not identify the majority of those infected. Trends need to be followed and further studies conducted in an attempt to define which adolescents are at highest risk for HIV infection.

Anticoagulation therapy in children with mechanical prosthetic cardiac valves.

From 1980 through 1984, 28 children younger than 19 years (mean 7.9) underwent cardiac valve replacement with 30 mechanical prostheses. Patients were followed for a total of 471 months (mean 15.7) and received either warfarin (mean 0.16 mg/kg/day) or acetylsalicylic acid and dipyridamole (mean 6.1 and 1.9 mg/kg/day, respectively) as thromboembolism prophylaxis. The frequency and incidence of thromboembolism and hemorrhage were compared. Warfarin-treated patients were at increased risk of hemorrhage (5 of 20 [25%], or 22 per 100 patient-years, vs 0 of 10 [0%], or 0 per 100 patient-years, p less than 0.05). Three of the 5 hemorrhagic episodes were mild, and in no case was hemorrhage life-threatening. Patients who did not receive warfarin had a greater risk of thromboembolism (2 of 10 [20%], or 12 per 100 patient-years, vs 0 of 20 [0%], or 0 per 100 patient-years, p less than 0.05). Both episodes of thromboembolism were life-threatening and necessitated emergency valve replacement. Although warfarin is associated with greater risk of hemorrhage than is acetylsalicylic acid and dipyridamole, warfarin is better than antiplatelet drugs in thromboembolism prophylaxis and is indicated for anticoagulation therapy in children with mechanical cardiac prostheses.

Aerosolized ribavirin in the treatment of patients with respiratory syncytial virus disease.

Thirty children 1 to 33 months of age were enrolled in a study of aerosolized ribavirin therapy for respiratory syncytial virus lower respiratory tract illness. Twenty patients received ribavirin and 10 received placebo. There were no significant differences between the groups in chronologic or gestational age or in days of illness prior to admission. Among patients with pneumonia 17% of 6 placebo patients vs. 64% of 11 ribavirin patients had radiographic evidence that multiple lung lobes were affected (P = 0.06). Placebo patients received 42.5 to 94.7 hours (mean, 58.6) of aerosol therapy, whereas ribavirin patients received 36.3 to 95.6 hours (mean, 55.7). Seventy-seven percent of all study patients were discharged within 5 days of starting treatment. Severity of illness was evaluated daily using a scale of 0 (normal) to 4+ (most severe). Ribavirin patients initially had a mean severity score 0.5 higher than placebo patients. By Day 2, their rate of improvement was significantly greater than that of placebo patients (P = 0.001). By Day 5, 36% of ribavirin patients with rales showed improvement, whereas rales persisted in 100% of placebo patients. The rate of improvement of oxygen saturation from first to last day of treatment was statistically significant only for ribavirin patients (P = 0.02). On Day 3, 65% of ribavirin patients (13) vs. 50% (5) placebo patients shed 10(-0.5) 50% tissue culture infective dose virus per 0.2 ml of nasal wash. No side effects or toxicity were associated with aerosol therapy. A short course of ribavirin treatment (approximately 3 days) proved safe and beneficial.

Escherichia coli virulence factors and 99mTc-dimercaptosuccinic acid renal scan in children with febrile urinary tract infection.

Correlation of virulence factors of Escherichia coli with renal inflammation documented by 99mTc-dimercaptosuccinic acid renal scan was undertaken in 59 children with febrile urinary tract infections to identify more accurately the role of bacterial virulence factors in the development of pyelonephritis. P fimbriae were present in 63% of isolates from the positive scan group and 83% of those from the negative scan group (P = 0.126). Multivariate regression analysis showed no significant role for established E. coli virulence factors in the development of pyelonephritis. The pap genome was independently associated with negative scan (P less than 0.007) and with the absence of reflux (P = 0.031). E. coli pyelonephritogenic clone O16:K1:H6 was isolated from negative scan patients and did not produce hemolysin. We conclude that P fimbriae are important in the development of febrile urinary tract infection regardless of the level of infection. Virulent E. coli clones described in prior Scandinavian urinary tract infection studies were not common causes of pyelonephritis in our patient population.

Assessing student performance on a pediatric clerkship.

OBJECTIVE: To determine whether any of 4 parameters used as evaluation methods in the pediatric clerkship at Children's National Medical Center, Washington, DC, could predict a student's performance, as measured by the final grade. DESIGN: A retrospective study in which the following data were collected: (1) a record of the diagnoses and total number of patients seen during the rotation, (2) clinical performance grade, (3) the National Board of Medical Examiners (NBME) pediatric shelf test score, (4) case presentation grade, and (5) the final clerkship grade for overall performance. SETTING: Third-year pediatric clerkship in the 1987-1988 academic year at Children's National Medical Center, the George Washington University School of Medicine. RESULTS: A total of 128 students had complete data. Correlations among the clinical parameters, ie, number of patients seen, clinical grade, case grade, and the NBME shelf test score were all statistically nonsignificant. In addition, multiple regression modeling of NBME test scores, using measures such as clinical grade, average case grade, and number of patients seen, was unsuccessful, with only clinical performance entering the regression model. In contrast, modeling of the final clerkship grade resulted in explaining almost 80% of the variation on a student's final grade (R2 = 0.79). Variables submitted to the model were number of patients seen, clinical grade, average case presentation grade, and ordered examination score. Last, a highly significant relationship (chi 2 = 15.98, P < .001) was noted between students receiving a final grade of honors and an "A" on their case grade. CONCLUSIONS: Results confirmed that there is no single best predictor of performance on a pediatric clerkship. While there was only a weak correlation between each single measure and the final grade, together these accounted for 80% of the variation in students' scores. Based on the study data, the use of varied evaluative methods to determine a student's final grade is recommended.

Quality of long-term survival in young children with medulloblastoma.

The reported success of treatment for children with medulloblastoma must be balanced against the effect that treatment has on the quality of life of long-term survivors. The outcome of long-term survivors reported in previous studies has been conflicting. The authors evaluate the mental and behavioral skills of a group of medulloblastoma survivors from their institution, all of whom had survived for more than 5 years postdiagnosis. A review of the institutional records yielded 32 patients. Twenty-three families were interviewed by telephone and, of these, 13 subjects came to the hospital for detailed neuropsychological and neurological evaluations. Intelligence quotient (IQ) was less than 90 for all participants tested, and patients diagnosed before the age of 3 years had lower IQ scores on average than those diagnosed later. Mean IQ and achievement test scores in reading, spelling, and mathematics were all higher in survivors who had undergone shunting. Achievement test results were often not in accord with intellectual potential, and individual intellectual skills varied widely. Perceptual-motor task performance was below average in more than 50% of the participants, but motor dexterity was more severely affected than perception. Problems in learning and a delay in both physical growth and development were seen in a majority of participants. This study directs attention to the serious difficulties faced by long-term survivors of medulloblastoma and their families, and underscores the importance of routine neuropsychological testing. Moreover, the study provides further impetus to seek alternatives to irradiation in the treatment of malignant brain tumors.

The potential toxicity to neonates of multivitamin preparations used in parenteral nutrition.

This study compares two groups of infants weighing less than 1500 g at birth. In the propylene glycol (PG) group, 30 infants received MVI-Concentrate containing 300 mg of PG daily with their intravenous nutrition (ivn), and vitamin E, 50 mg/week by intramuscular injection. In the mannitol group, 30 infants received MVI-Pediatric (containing 245 mg mannitol), 65% of a vial/day. Serum and urine osmolality, serum PG, blood-urea-nitrogen, creatinine, sodium, and glucose were measured on days 0, 2, 5, 12, 19, 26, 33 and 40 of ivn. Weight, urine output, and fluid intake were measured daily. Vitamin E levels were measured on days 5, 26, and 33 of ivn. There were no significant differences between the groups in birth weight, gestational age, sex, age, or weight at start of ivn. Our results indicated that neither MVI-Concentrate nor MVI-Pediatric was associated with a clinically significant diuresis. MVI-Pediatric, 65% of a vial/day, may produce higher than desirable blood levels of vitamin E, and use of drugs containing PG can produce significant blood levels of PG, in very low birth weight infants.

Alcohol and drug use in teenagers with diabetes mellitus.

Alcohol and drug use in adolescents with diabetes mellitus was assessed by an anonymous self-administered questionnaire with verification by urine drug screening. Approximately 50% of these adolescents report having tried alcohol and 25% report ongoing use. Almost 25% have tried drugs of abuse and 5% report ongoing use. One of 97 consecutive urine specimens was positive for marijuana. In general, the frequency of alcohol and drug use was less than expected based on other studies of different clinical groups of patients in the same age range. Patients with diabetes who reported drug use or who reported they live in an environment of substance abuse had poorer diabetes control than patients who did not.

Long-term results of bifocal therapy for accommodative esotropia.

We studied the long-term course of 65 accommodative esotropes who required bifocals to maintain alignment at near. Average follow-up was 10.5 years. Forty patients (61.5%, group DC [bifocals discontinued]) were able to discontinue bifocal use after an average of 5.5 years wear. Twenty-five (38.5%) continued to wear bifocals (or a suitable alternative such as reading glasses), after an average 9.7 years of follow-up. Surgical correction of deteriorated accommodative esotropia was performed for 20 patients (50%) in group DC, and nine (36%) of those in group C[bifocals continued]. Surgery produced an average reduction in the accommodative convergence relationship (near esodeviation in prism diopters [pd] minus corrected distance measurement, AC/A) of approximately 10 pd in both groups. Surgical patients unable to discontinue bifocal wear began with a clinically higher AC/A than those in group DC. Non-surgical patients in group DC experienced spontaneous improvement of the AC/A over time (average, 6.2 pd). On average, this did not occur in those of group C. Average age of bifocal discontinuation was 9.7 years in surgical patients and 9.3 years in the non-surgical. Surgical patients had significantly lower hyperopia (+2.4 diopters [D]), than non-surgical (+3.5 D), and an earlier age of onset of bifocal wear (3.29 versus 4.64 years). Although bifocals may be successfully discontinued in a majority of patients at an average age of 9.5 years, a significant percentage require long-term wear, some, despite surgery. The only factor that predicted long-term bifocal wear was a relatively high AC/A.

Rate of deterioration in accommodative esotropia correlated to the AC/A relationship.

We analyzed the claim that accommodative esotropia tends to deteriorate with greater frequency if the accommodation convergence relationship (AC/A) is high. Records of 119 patients whose eyes were aligned with spectacles alone were studied. Their AC/A relationships were graded according to the difference between the distance and near measurements: normal included 0 to 9 prism diopters (delta) difference; grade 1 ranged from 10 to 19 delta difference; grade 2 from 20 to 29 delta difference; and in grade 3 the difference was 30 delta or greater. Deterioration is characterized by a nonaccommodative component of esotropia greater than 10 delta at distance becoming superimposed on the initial accommodative esotropia. Deterioration occurred in 7.7% of patients with a normal AC/A, 25% with grade 1 high AC/A, 44% with grade 2 high AC/A, and 52% with grade 3 high AC/A. Hypotheses were investigated using chi square, t-test, analysis of variance (ANOVA), and log linear analyses. Distributional differences were highly significant by chi square test (p = 0.001) with a rejection of the null hypothesis of no difference between the groups at the alpha = 0.05 level. An alternate analysis of average AC/A ratio in the deteriorated versus nondeteriorated patients was equally statistically significant by the t-test. Hypermetropia was significantly higher in the normal AC/A group. Multi-factor comparisons showed that time-to-deterioration, treatment delay, age of onset, and amblyopia were factors that did not relate significantly to the incidence of deterioration.

Assessing African American adolescents' risk for suicide attempts: attachment theory.

The threat of separation from a parent theoretically increases the risk of adolescent suicide attempts. The present study evaluated this and other hypothesized risk factors in a sample of adolescent suicide attempters and nonsuicidal controls, using the Psychiatric Consultation Checklist (Lyon, 1987). Stepwise logistic regression was used to predict group membership. It was found that threat of separation from a parental figure, insomnia, neglect, substance abuse, suicidal ideation, and failing grades were the strongest predictors of suicide attempt. Ten predictor variables correctly identified 97% of suicide attempters and 86% of nonattempters. Unexpected findings included high levels of truancy, threatening others, and separation from a parent before the age of 12 among nonattempters.

Pediatric critical care cost containment: combined actuarial and clinical program.

OBJECTIVE: To determine if providing patients' daily survival probabilities to physicians and nurses along with a short videotape on the measurement of survival probabilities and costs of pediatric intensive care would reduce resource use. DESIGN: Prospective, randomized, controlled trial. SETTING: Pediatric ICU. PATIENTS: Medical patients in a prospective control period (n = 113), an intervention period (n = 226), and a follow-up control period (n = 97). INTERVENTIONS: The survival probabilities of 50% of the patients in the intervention period were displayed at the bedside and the staff viewed a short videotape on the measurement of survival probabilities and costs of pediatric intensive care. MEASUREMENTS AND MAIN RESULTS: Daily survival probabilities and resource use were evaluated each day. Resource use, adjusted for severity of illness, was evaluated using analysis of covariance. Compared with the prospective control group, reductions in the daily use of blood gases (p less than .01), hematology tests (p less than .001), hourly vital signs (p less than .001), and hourly neurologic vital signs (p less than .001) resulting in a composite reduction in daily laboratory and imaging charges from $759 +/- $22 to $622 +/- $18 (p less than .01) were observed in the patient group receiving the survival probabilities and whose physicians also viewed the videotape. Equivalent reductions in resource use also occurred in a simultaneous control group (patients did not receive survival probabilities but healthcare workers did view the videotape) and in a follow-up control group. CONCLUSION: Reduction in pediatric intensive care resource use can occur from the combined effects of actuarial and clinical interventions.

Pediatric risk of mortality (PRISM) score.

The Pediatric Risk of Mortality (PRISM) score was developed from the Physiologic Stability Index (PSI) to reduce the number of physiologic variables required for pediatric ICU (PICU) mortality risk assessment and to obtain an objective weighting of the remaining variables. Univariate and multivariate statistical techniques were applied to admission day PSI data (1,415 patients, 116 deaths) from four PICUs. The resulting PRISM score consists of 14 routinely measured, physiologic variables, and 23 variable ranges. The performance of a logistic function estimating PICU mortality risk from the PRISM score, age, and operative status was tested in a different sample from six PICUs (1,227 patients, 105 deaths), each PICU separately, and in diagnostic groups using chi-square goodness-of-fit tests and receiver operating characteristic (ROC) analysis. In all groups, the number and distribution of survivors and nonsurvivors in adjacent mortality risk intervals were accurately predicted: total validation group (chi 2(5) = 0.80; p greater than .95), each PICU separately (chi 2(5) range 0.83 to 7.38; all p greater than .10), operative patients (chi 2(5) = 2.03; p greater than .75), nonoperative patients (chi 2(5) = 2.80, p greater than .50), cardiovascular disease patients (chi 2(5) = 4.72; p greater than .25), respiratory disease patients (chi 2(5) = 5.82; p greater than .25), and neurologic disease patients (chi 2(5) = 7.15; p greater than .10). ROC analysis also demonstrated excellent predictor performance (area index = 0.92 +/- 0.02).

Accurate prediction of the outcome of pediatric intensive care. A new quantitative method.

We surveyed nine pediatric intensive care units (ICUs) to compare patient populations and to test prospectively the hypothesis that differences in mortality rates were due to differences in severity of illness. Age, clinical service, the reason for admission (emergency or scheduled), and the seriousness of the underlying chronic disease were recorded on admission. The severity of illness was assessed on the day of admission with a physiology-based measure, the Physiologic Stability Index. The resulting score was used to group patients according to mortality risk. The observed numbers of ICU survivors and nonsurvivors in each mortality-risk group from eight of the pediatric ICUs were compared with the predicted numbers of survivors and nonsurviors calculated from a mathematical function (logistic model) derived earlier from data on 822 patients at one of the institutions. Patient populations in the ICUs differed significantly with respect to age (range of medians, 15 to 36 months; P less than 0.0001), medical admissions (range, 39 to 81 percent; P less than 0.0001), emergency admissions (range, 53 to 91 percent; P less than 0.0001), and the percentage of patients with serious underlying chronic disease (range, 18 to 48 percent; P less than 0.0001). Mortality rates also differed significantly (range, 3.0 to 17.6 percent; P less than 0.0001), as did the Physiologic Stability Index scores (P less than 0.0001). The mathematical function based on the Physiologic Stability Index score and on age reliably predicted the outcomes in all ICUs. We conclude that differences in mortality rates among pediatric ICUs can be explained by differences in the severity of illness.

Cost, resource utilization, and severity of illness in intensive care.

The relationship between health care resource use and severity of illness is important to hospitals providing care to sicker patients, so we investigated the relationship between resource utilization, cost, and severity of illness in 229 consecutive patients admitted to a pediatric intensive care unit. Resources measured included length of stay and number and cost of laboratory and imaging studies. Pediatric intensive care unit and daily mortality risks (assessed by the Physiologic Stability Index and the Dynamic Risk Index) were stratified as very low risk (less than 1%), low risk (1% to 2.5%), moderate risk (2.5% to 5.0%), and high risk (greater than 5%). Increasing daily resource use was directly related to increasing gradations of severity of illness. For very low, low-, moderate-, and high-risk patient days, the daily numbers of diagnostic studies were (mean +/- SEM) 20.1 +/- 0.6, 31.4 +/- 1.1, 37.7 +/- 1.6, and 43.0 +/- 1.8, respectively. Total resource use, including diagnostic tests and length of stay, also increased with pediatric intensive care unit mortality risk. Diagnostic testing and corresponding costs were significantly higher for infants who died in the pediatric intensive care unit than for survivors on a day-by-day basis as well as for the entire stay in the care unit. We conclude that there is a direct, positive relationship between resource use, cost, and gradations of severity of illness that, if accounted for, would result in more equitable health care reimbursement.

Pediatric intensive care units: results of a national survey.

OBJECTIVE: To describe the structure and organization of pediatric intensive care units (ICUs) in the United States. SURVEY METHODS: We directed a mail survey to pediatric ICU medical and nursing directors and hospital quality assurance officers. A total of 201 of 301 hospitals with pediatric ICUs initially responded. Telephone confirmation of the mail survey (n = 193) and telephone data collection for mail survey nonresponders (n = 42) were also undertaken. SURVEY RESULTS: The largest proportion (40.0%) of pediatric ICUs had four to six beds per unit, while only 6.0% had > 18 beds per unit. The admissions per year averaged 528 +/- 24, and the mortality rates averaged 5.5 +/- 0.2%. Only 79.6% of the pediatric ICUs had full-time medical directors. A pediatric intensivist was available to 73.2% of the units. Physician coverage for 24 hrs/day dedicated only to the pediatric ICU was present in 48.5% of hospitals. As ICU size increased, the estimated mortality rates increased, as did the percentages with full-time directors, pediatric intensivists, and 24 hrs/day dedicated coverage. Medical school affiliation existed for 79.6% of pediatric ICU hospitals, and 81.1% of these hospitals were the primary teaching program sites for pediatrics. Other ICUs caring for children were present in 30.2% of the hospitals. SURVEY APPLICATION: The mail survey respondents were stratified using four factors: size, teaching status, intensivist status, and coordination of care status. A total of 16 respondents were randomly selected for an ongoing outcomes study of the importance of these factors. CONCLUSIONS: Substantial diversity exists in pediatric ICU structure and organization. Determining factors associated with quality of care is important for improving outcomes.