RESUMEN
OBJECTIVE: To define the natural history and outcomes of children infected with hepatitis C virus (HCV) at birth or in early childhood. STUDY DESIGN: This retrospective, prospective study identified 60 HCV-infected children through a transfusion look-back program (group 1) and by referrals (group 2). Perinatal/transfusion history, clinical course, and laboratory studies were correlated with findings from 42 liver biopsy specimens. RESULTS: Mean age at infection was 7.1 months, and duration of infection 13.4 years. The sources of infection were blood transfusion (68%), perinatal transmission (13%), and both (7%). Most patients were asymptomatic; three referral patients had advanced liver disease at presentation. Mean alanine aminotransferase level was normal in 25%, 1 to 3 times normal in 62%, and greater than 3 times normal in 13%. Liver biopsy specimens showed minimal to mild inflammation in 71%, absent or minimal fibrosis in 88%, and bridging fibrosis in 12%. Age at infection and serum gamma-glutamyltranspeptidase correlated with fibrosis; serum alanine aminotransferase correlated with inflammation unless complicated by comorbidity. Repeat biopsies within 1 to 4 years in four patients showed no significant progression in three and cirrhosis in one. Two patients died after liver transplantation. CONCLUSIONS: Children with chronic HCV infection are generally asymptomatic. By 13 years after infection, 12% of patients had significant fibrosis. Patients enrolled by referral had more severe liver disease than those identified through the look-back program, demonstrating the importance of selection bias in assessing the long-term outcome of HCV infection.
Asunto(s)
Hepatitis C Crónica/patología , Hepatitis C Crónica/fisiopatología , Cirrosis Hepática/patología , Biopsia con Aguja , Niño , Preescolar , Progresión de la Enfermedad , Femenino , Anticuerpos contra la Hepatitis C/análisis , Humanos , Lactante , Cirrosis Hepática/virología , Modelos Logísticos , Masculino , Probabilidad , Pronóstico , Estudios Prospectivos , ARN Viral/análisis , Estudios Retrospectivos , Medición de Riesgo , Índice de Severidad de la Enfermedad , Estadísticas no Paramétricas , Factores de Tiempo , Reacción a la TransfusiónRESUMEN
OBJECTIVE: We evaluated overutilization or underutilization of inpatient resources to measure the emergency department (ED) decision-making process and its association with the following care factors: annual pediatric volume, presence or absence of a pediatric emergency medicine specialist; and presence or absence of ED residents. STUDY DESIGN: Block random selection, using the three care factors, of 16 hospitals with pediatric intensive care units. The Pediatric Risk of Admission (PRISA II) Score was used to measure illness severity. Decision-making was evaluated for admissions (Admission Index: observed minus predicted admissions) and returns (Return Index: observed minus predicted 72-hour returns). The Combined Index was a weighted average of the Admission and Return Indexes. RESULTS: There were 11,664 patients enrolled. Residents but not volume or pediatric emergency medicine specialists were associated with the decision-making performance indexes in multivariable analysis (no residents versus residents: Admission Index: 2.5 of 1000 patients versus 34.8 of 1000, P = .082; Return Index: -3.0 of 1000 versus 33.6 of 1000, P = .039; Combined Index: 1.9 of 1000 versus 35.5 of 1000, P = .024. CONCLUSIONS: There is significant variability in ED decision-making for children. Residents but not volume or presence of a pediatric emergency medicine specialist are associated with increased differences in admission decisions. The process by which these differences occur was not investigated.
Asunto(s)
Toma de Decisiones , Servicio de Urgencia en Hospital/estadística & datos numéricos , Admisión del Paciente , Alta del Paciente , American Hospital Association , Análisis de Varianza , Ocupación de Camas , Niño , Preescolar , Bases de Datos Factuales , Medicina de Emergencia , Femenino , Recursos en Salud/estadística & datos numéricos , Humanos , Unidades de Cuidado Intensivo Pediátrico/estadística & datos numéricos , Internado y Residencia , Masculino , Proyectos de Investigación , Medición de Riesgo , Índice de Severidad de la Enfermedad , Análisis y Desempeño de Tareas , Estados Unidos/epidemiología , Recursos HumanosRESUMEN
OBJECTIVE: To test the hypothesis that red blood cell transfusions are associated with increased resource utilization and mortality in critically ill children. METHODS: Five pediatric intensive care units (PICUs) participated in a retrospective, cohort analysis (1996-1999). Children with a hemoglobin value Asunto(s)
Anemia/terapia
, Enfermedad Crítica/terapia
, Transfusión de Eritrocitos/efectos adversos
, Transfusión de Eritrocitos/estadística & datos numéricos
, Recursos en Salud/estadística & datos numéricos
, Unidades de Cuidado Intensivo Pediátrico/estadística & datos numéricos
, Pediatría/estadística & datos numéricos
, Pautas de la Práctica en Medicina/estadística & datos numéricos
, Anemia/sangre
, Anemia/etiología
, Anemia/mortalidad
, Niño
, Preescolar
, Enfermedad Crítica/mortalidad
, Delaware/epidemiología
, District of Columbia/epidemiología
, Investigación sobre Servicios de Salud
, Hemoglobinas/análisis
, Mortalidad Hospitalaria
, Humanos
, Tiempo de Internación/estadística & datos numéricos
, Maryland/epidemiología
, New Jersey/epidemiología
, Terapia por Inhalación de Oxígeno/estadística & datos numéricos
, Selección de Paciente
, Análisis de Regresión
, Respiración Artificial/estadística & datos numéricos
, Estudios Retrospectivos
, Índice de Severidad de la Enfermedad