Healthcare-Based Interventions to Improve Parenting Outcomes in LMICs: A Systematic Review and Meta-Analysis.

OBJECTIVES: Although a number of early childhood development (ECD) interventions in healthcare settings in low- and middle-income countries (LMICs) have been developed to improve parent-directed outcomes and support ECD, their impact have yet to be established. This review assesses the effectiveness of healthcare-based ECD interventions in LMICs on the following key evidence-informed parenting outcomes affecting ECD: (1) responsive caregiving (2) cognitive stimulation and (3) parental mental health. Impacts on parental knowledge regarding ECD and parenting stress were also assessed. METHODS: PubMed, PsycINFO, Scopus, CINAHL and Embase were searched. We included randomized controlled trials reporting effects of healthcare-based ECD interventions in LMICs on parent-directed outcomes in the first five years of life. Data extraction included study characteristics, design, sample size, participant characteristics, settings, intervention descriptions, and outcomes. Meta-analyses were conducted using random effects models. RESULTS: 8 articles were included. Summary standardized mean differences demonstrated significant benefits of healthcare-based interventions in LMICs for improving: (1) cognitive stimulation (n = 4; SMD = 0.32; 95% CI: 0.08 to 0.56) and (2) ECD knowledge (n = 4; SMD = 0.44; 95% CI: 0.27 to 0.60). No significant effects were seen on maternal depression and parenting stress; only one study assessed parent-child interactions in the context of responsiveness. Limitations included small number of studies for moderation analysis, high heterogeneity, variability in measures used for outcomes and timing of assessments. CONCLUSIONS FOR PRACTICE: Our results demonstrate statistically significant effects of healthcare-based interventions in LMICs on improving key evidence-based parenting outcomes and offers one promising strategy to support children reach their full developmental potential.

Antenatal factors for neonatal seizures among late preterm births*.

OBJECTIVE: The objective of this study was to evaluate for antenatal risk factors for neonatal seizures among late preterm births. STUDY DESIGN: This was a case control study which included late preterm births without anomaly from the United States Natality database. Cases were infants with neonatal seizures, while the controls consisted of infants without neonatal seizures. Maternal and pregnancy characteristics were compared. Multivariable logistic regression was performed to investigate risk factors for neonatal seizures. RESULTS: Of the 943,580 late preterm births, 512 (0.05%) developed neonatal seizures. Significant risk factors associated with neonatal seizures among late preterm births included number of prenatal visits (adjusted odds ratio [aOR] 0.94, 95% CI [0.92-0.96]), smoking history (aOR 1.78, 95% CI [1.41-2.25]), chorioamnionitis (aOR 4.37, 95% CI [2.65-7.21]), non-Hispanic White race (aOR 1.41, 95% CI [1.13-1.76]), and cesarean birth (aOR 2.31, 95% CI [1.91-2.80]). CONCLUSION: Number of prenatal visits, history of smoking, chorioamnionitis, non-Hispanic white race, and cesarean birth are risk factors for neonatal seizures at late preterm gestation.

Presentation, Management and Outcomes of Pediatric Pulmonary Embolus: A Retrospective Review.

OBJECTIVES: To review the presentation, management, and outcomes of pediatric pulmonary embolism (PE) patients treated at a single institution over 10 years to determine whether laboratory findings and clinical presentation predict disease severity. METHODS: We performed a retrospective chart review of patients treated for PE in a 14-bed pediatric intensive care unit from January 1, 2008, to December 31, 2018. Associations between clot burden and disease severity, clinical risk factors (body mass index, recent hospitalization, estrogen use), clinical presentation (heart rate, oxygen saturation), and laboratory values (white blood cell count, D-Dimer, troponin, proBNP) were performed using Student t test, χ2 tests, and 1-way analysis of variance. Patients were risk stratified by American Heart Association guidelines. RESULTS: Eighteen (72%) patients (girls) were treated for PE. Common risk factors included recent hospitalization (67%) and oral contraceptives (62%). Risk factors, clinical presentation (including hypoxemia and tachypnea), and laboratory studies did not correlate with disease severity or clot burden. Electrocardiogram and radiographic findings were non-specific. Computer tomography pulmonary angiography (CTPA) was required to diagnose 94%. Sixteen received unfractionated heparin, and 5 required additional intervention. Risk factors, clinical features, and laboratory studies did not predict who required intervention. CONCLUSIONS: Of 18 pediatric patients treated for PE at a single institution over 10 years, vital signs and laboratory data did not predict disease severity or clot burden, and CTPA was required for diagnosis in all but 1. Emergency room providers must have a high index of suspicion for diagnosis and cannot be reassured by normal electrocardiogram or plain film findings. At a time when pediatric providers are under pressure to minimize unnecessary radiation exposure, this lack of correlation of clinical presentation and laboratory findings highlights the importance of considering CTPA when PE is suspected.

A Systematic Review of the Effect of Physical Activity on Asthma Outcomes.

BACKGROUND: Asthma is a chronic respiratory disease that affects millions worldwide. Medication management is the current mainstay of treatment; however, there is evidence to suggest additional benefit with lifestyle changes, particularly with increased physical activity. OBJECTIVE: To discover and evaluate the effects of physical activity on asthma outcomes. METHODS: Systematic search of PubMed, Excerpta Medica database, Cumulative Index to Nursing and Allied Health Literature, Cochrane Library, Rehabilitation and Sports Medicine Source, Scopus, and Web of Science identified 11,155 results. Thirty-five articles met our inclusion criteria spanning 20 studies. Data extraction was conducted by 6 independent reviewers, and final results were evaluated by a seventh reviewer and the senior author. RESULTS: Wide variation among selected studies, including the heterogeneity of interventions and outcome variables, did not support a meta-analysis. Mixed results of the effects of physical activity on asthma outcomes were found. Most studies suggest that physical activity improves asthma control, quality of life, lung function parameters, and inflammatory serologies, whereas 3 found no improvements in any of these outcomes. No studies reported worsening asthma outcomes. CONCLUSIONS: This review highlights the emerging and promising role of physical activity as a nonpharmacologic treatment for asthma. Additional high-quality randomized controlled trials are needed to overcome the problems of measurement heterogeneity and the dilution of outcome effect size measurement related to physical activity interventions for asthma.

Children's Drawings With Narratives in the Hospital Setting: Insights Into the Patient Experience.

OBJECTIVES: To explore PICU patients' experiences and perceptions through their drawings with explanatory narratives. METHODS: Single-center prospective study in a 14-bed PICU in a tertiary care, academic-affiliated hospital. Pediatric patients age 6 to 17 years admitted to the PICU were approached to participate within 12 hours of transfer out of the PICU. Patients completed a brief study interview to identify the best and worst things about their PICU experience. Patients were asked to draw a picture of their experiences and then explain their drawings to study staff. RESULTS: Forty patients (median age 11 [6-17] years) agreed to participate. The median length of PICU stay was 2 days. The best aspects of the PICU stay included staff (25%), entertainment devices (15%), and food (13%). The worst aspects of the PICU stay that were reported were the intravenous line (25%), alarms (10%), and physical discomfort (10%). The most common elements in drawings were self-depictions (88%), monitors (53%), the intravenous line (50%), registered nurses (35%), and television (33%). Patient narratives related to their drawings provided additional insights regarding patient experiences in the PICU and identified various coping mechanisms used by patients to adapt to their experiences. CONCLUSIONS: Drawing, along with explanation, enables patients admitted to a PICU to disclose additional unique descriptive information about their experiences as patients. Facilitating this mode of communication may increase providers' awareness of positive and negative aspects of a PICU admission and may be used to improve pediatric patients' experiences in the hospital setting.

Impact of Pediatric Intensive Care Unit Admission on Family Financial Status and Productivity: A Pilot Study.

OBJECTIVE: A child's pediatric intensive care unit (PICU) admission may have wide-ranging family implications. We assessed nonmedical out-of-pocket expenses (NMOOPEs) and disruptions in work and normal life for parents with a child admitted to the PICU for at least 2 days with acute, new onset, or exacerbation of a critical condition. DESIGN: We conducted a prospective, single-center study; administered a daily verbal response survey on NMOOPEs; stratified families by annual income (<$50 999, $51-99 000, >$100 000); and calculated daily expenditures (DEs), estimated daily budgets (DBs), and percentage of NMOOPEs (%DE/DB). We used a modified caregiver version of the Work Productivity and Activity Impairment Scale to assess the impact of PICU admission on work-related and normal life activities. SETTING: The PICU in an academic, tertiary medical center in the United States. PATIENTS: Patients admitted to PICU. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The study included 38 families, with median length of PICU stay of 3 days (range 3-13). The mean total NMOOPE was $127 ± $107 (range $5-$511). Financial impact of DB in the 3 annual income groups ranged from 0% to 136% (median 36%), 5% to 18% (median 10%), and 4% to 39% (median 16%), respectively. Total work absenteeism for cohort was 78 days. High levels of distraction were reported in working families, and normal daily activities were interrupted or suspended. CONCLUSIONS: PICU hospitalization results in a range of direct NMOOPEs of varying burden on families and additional work productivity impact. Further research to understand the array of financial implications on families and additional mitigation strategies are needed.

Long-term telemental health prevention interventions for youth: A rapid review.

INTRODUCTION: This rapid review identifies and summarizes the effectiveness of preventative telemental health interventions. It investigates studies conducted between 2010 and 2016 that improve mood and anxiety with long-term follow-up. METHODS: A literature search of three major databases was performed by four reviewers. After citation tracing, 3604 studies were discovered, and twenty of these met the inclusion criteria. Data from the papers were abstracted, assessed for quality, and effect sizes were calculated. RESULTS: Salient information was discussed using the Behavioural Vaccine Model of mental illness prevention. This included key concepts such as efficacy, duration of benefits, sociocultural relevance, professional guidance, peer-to-peer support, adherence, delivery and safety. CONCLUSION: This review suggests there are clear prolonged benefits to using technology in youth mental illness prevention. Although this is a rapidly growing area of investigation in countries around the globe, there is still a dearth of research with long-term follow-up. Future studies should aim to boost engagement by increasing motivational guidance in order to recruit at-risk youth of all demographics into these promising intervention programs.

Substance-exposed newborn infants and public health law: Differences in addressing the legal mandate to report.

Prenatal exposure to illicit substances is a finding that typically requires reporting to a child protective services agency. We examine whether there is differential reporting to two public agencies, and whether it varies by race/ethnicity and region. We also study predictors of indicating a maltreatment report as credible. Data on positive neonatal toxicology reports were obtained from the Illinois Department of Public Health (IDPH) and the Illinois Department of Children and Family Services (DCFS). Variation in reporting rates by race/ethnicity and region were compared with Pearson chi-square analysis. Multivariate logistic regression examined factors related to the likelihood of DCFS indicating a report as credible for maltreatment. IDPH recorded 1838 reports of substance-exposed newborn infants while DCFS only recorded 459 reports. There was a greater percentage of whites than blacks reported to DCFS as compared to those reported to IDPH (p < 0.001). There was a greater percentage of whites than blacks found to be indicated by DCFS as compared to those reported to IDPH (p < 0.001). Infants reported in rural areas were indicated less often (OR:0.34, 95% CI:0.17-0.67, p = 0.002) than those from urban areas. In conclusion, there was variation in reporting patterns between the two agencies. To optimize health outcomes for substance-exposed newborn infants (SEIs), the law should be clarified to provide clear standards for reporting and managing SEIs. Clinicians should ensure they are acting within the confines of existing law, and should engage in an interprofessional process with a broad array of stakeholders to develop statewide drug testing and reporting protocols.

A critical narrative review of transfer of basic science knowledge in health professions education.

CONTEXT: 'Transfer' is the application of a previously learned concept to solve a new problem in another context. Transfer is essential for basic science education because, to be valuable, basic science knowledge must be transferred to clinical problem solving. Therefore, better understanding of interventions that enhance the transfer of basic science knowledge to clinical reasoning is essential. This review systematically identifies interventions described in the health professions education (HPE) literature that document the transfer of basic science knowledge to clinical reasoning, and considers teaching and assessment strategies. METHODS: A systematic search of the literature was conducted. Articles related to basic science teaching at the undergraduate level in HPE were analysed using a 'transfer out'/'transfer in' conceptual framework. 'Transfer out' refers to the application of knowledge developed in one learning situation to the solving of a new problem. 'Transfer in' refers to the use of previously acquired knowledge to learn from new problems or learning situations. RESULTS: Of 9803 articles initially identified, 627 studies were retrieved for full text evaluation; 15 were included in the literature review. A total of 93% explored 'transfer out' to clinical reasoning and 7% (one article) explored 'transfer in'. Measures of 'transfer out' fostered by basic science knowledge included diagnostic accuracy over time and in new clinical cases. Basic science knowledge supported learning - 'transfer in' - of new related content and ultimately the 'transfer out' to diagnostic reasoning. Successful teaching strategies included the making of connections between basic and clinical sciences, the use of commonsense analogies, and the study of multiple clinical problems in multiple contexts. Performance on recall tests did not reflect the transfer of basic science knowledge to clinical reasoning. CONCLUSIONS: Transfer of basic science knowledge to clinical reasoning is an essential component of HPE that requires further development for implementation and scholarship.

Optimal wound care management in hidradenitis suppurativa.

INTRODUCTION: Hidradenitis suppurativa (HS) presents the problem of a chronic, relapsing, painful, draining wound. There is a myriad of HS wound care management strategies implemented by clinicians and patients centered around which dressings to use. Many factors affect which HS wound care dressing is the most appropriate to use such as the type of HS wound, cost, ease of application, patient comfort, absorbency and odor management among many others. AIM: In this work, the authors aim to prepare a set of guidelines for optimal HS wound care dressing use based on a tier system, ideal characteristics of HS dressings and the type of HS lesion. The dressing recommendations focus on cost-effectiveness for patients, ease of accessibility and ultimately, improvement in the quality of life of patients suffering from HS. METHODS: PubMed was utilized to search the terms 'wound care + HS'; 'non-surgical wound care + HS'; 'optimal wound care + HS'; 'HS wounds'; and 'optimal wound dressings'. RESULTS: Silver-impregnated foam is considered the most optimal HS wound care dressing because it contains nearly all characteristics of an ideal wound care dressing. CONCLUSION: However, silver-impreganted foam is expensive and difficult to access for patients, so lower-tier HS wound care dressings must be considered prior to utilizing this tier 4 dressing.

Systems-Based Training in Graduate Medical Education for Service Learning in the State Legislature in the United States: Pilot Study.

BACKGROUND: There is a dearth of advocacy training in graduate medical education in the United States. To address this void, the Legislative Education and Advocacy Development (LEAD) course was developed as an interprofessional experience, partnering a cohort of pediatrics residents, fourth-year medical students, and public health students to be trained in evidence-informed health policy making. OBJECTIVE: The objective of our study was to evaluate the usefulness and acceptability of a service-based legislative advocacy course. METHODS: We conducted a pilot study using a single-arm pre-post study design with 10 participants in the LEAD course. The course's didactic portion taught learners how to define policy problems, research the background of the situation, brainstorm solutions, determine evaluation criteria, develop communication strategies, and formulate policy recommendations for state legislators. Learners worked in teams to create and present policy briefs addressing issues submitted by participating Illinois State legislators. We compared knowledge and attitudes of learners from pre- and postcourse surveys. We obtained qualitative feedback from legislators and pediatric residency directors. RESULTS: Self-reported understanding of the health care system increased (mean score from 4 to 3.3, P=.01), with answers scored from 1=highly agree to 5=completely disagree. Mean knowledge-based scores improved (6.8/15 to 12.0/15 correct). Pediatric residency program directors and state legislators provided positive feedback about the LEAD course. CONCLUSIONS: Promising results were demonstrated for the LEAD approach to incorporate advocacy training into graduate medical education.

Parent Participation in Pediatric Intensive Care Unit Rounds via Telemedicine: Feasibility and Impact.

OBJECTIVES: To evaluate feasibility and impact of telemedicine for remote parent participation in pediatric intensive care unit (PICU) rounds when parents are unable to be present at their child's bedside. STUDY DESIGN: Parents of patients admitted to a 14-bed PICU were approached, and those unable to attend rounds were eligible subjects. Nurse and physician caregivers were also surveyed. Parents received an iPad (Apple Inc, Cupertino, California) with an application enabling audio-video connectivity with the care team. At a predetermined time for bedside rounds with the PICU team, parents entered a virtual meeting room to participate. Following each telemedicine encounter, participants (parent, physician, nurse) completed a brief survey rating satisfaction (0?=?not satisfied, 10?=?completely satisfied) and disruption (0?=?no disruption at all, 10?=?very disruptive). RESULTS: A total of 153 surveys were completed following 51 telemedicine encounters involving 13 patients. Parents of enrolled patients cited work demands (62%), care for other dependents (46%), and transportation difficulties (31%) as reasons for study participation. The median levels of satisfaction and disruption were 10 (range 5-10) and 0 (range 0-5), respectively. All parents reported that telemedicine encounters had a positive effect on their level of reassurance regarding their child's care and improved communication with the care team. CONCLUSIONS: This proof-of-concept study indicates that remote parent participation in PICU rounds is feasible, enhances parent-provider communication, and offers parents reassurance. Providers reported a high level of satisfaction with minimal disruption. Technological advancements to streamline teleconferencing workflow are needed to ensure program sustainability.

Primary Care-Based Interventions to Promote Positive Parenting Behaviors: A Meta-analysis.

CONTEXT: Utilization of primary care settings offers a promising approach to enhance parenting practices that are critical for promoting early childhood development. Determining the impact of existing primary care interventions on key parenting behaviors will aid providers and policy makers as they seek strategies to improve early child outcomes. OBJECTIVE: To evaluate the efficacy of primary care-based interventions on parenting practices that promote early child development among children younger than 36 months. DATA SOURCES: PubMed, Excerpta Medica dataBASE, PsycINFO, and Cumulative Index to Nursing and Allied Health Literature databases were searched electronically. STUDY SELECTION: English-language articles that were quasi-randomized or randomized controlled trials, included parents of children <36 months of age, and reported outcomes related to parenting behaviors that promote early child development. DATA EXTRACTION: Two reviewers independently extracted data regarding participants, interventions, and outcomes. Quantitative meta-analyses were conducted with random effects for study and fitted with restricted maximum likelihood methods. RESULTS: The review included 13 studies reporting parenting outcomes in 2 categories: participation in cognitively stimulating activities and positive parent-child interactions. We found a statistically significant positive effect of primary care-delivered interventions and parent-child interactions (summary standardized mean difference 0.29, 95% confidence interval [CI] 0.06-0.52, P < .0001) and participation in cognitively stimulating activities (summary standardized mean difference 0.34, 95% CI 0.03-0.54; summary odds ratio 0.13, 95% CI 0.01-0.25, P < .0001). LIMITATIONS: Limitations included heterogeneity in measures used, outcomes, and timing of assessments. CONCLUSIONS: Primary care-based interventions modestly affect positive parenting behaviors important for early childhood development. Randomized controlled trials with comparable outcome measures using standardized assessments are needed to assess further beneficial impacts.

Telemedicine Versus Face-to-Face Evaluations by Respiratory Therapists of Mechanically Ventilated Neonates and Children: A Pilot Study.

BACKGROUND: Mechanical ventilation is one of the most important therapeutic interventions in neonatal and pediatric ICUs. Telemedicine has been shown to reliably extend pediatric intensivist expertise to facilities where expertise is limited. If reliable, telemedicine may extend the reach of pediatric respiratory therapists (RTs) to facilities where expertise does not exist or free up existing RT resources for important face-to-face activities in facilities where expertise is limited. The aim of this study was to determine how well respiratory assessments for ventilated neonates and children correlated when performed simultaneously by 2 RTs face-to-face and via telemedicine. METHODS: We conducted a pilot study including 40 assessments by 16 RTs on 11 subjects (5 neonatal ICU; 6 pediatric ICU). Anonymously completed intake forms by 2 different RTs concurrently assessing 14 ventilator-derived and patient-based respiratory variables were used to determine correlations. RESULTS: Forty paired assessments were performed. Median telemedicine assessment time was 8 min. The Pearson correlation coefficient (r) was used to determine agreement between continuous data, and the Cohen kappa statistics were used for binary variables. Pressure control, PEEP, breathing frequency, and FIO2 perfectly correlated (r = 1, all P < .001) as did the presence of a CO2 monitor and need for increased ventilatory support (kappa = 1). The Pearson correlation coefficient for VT, minute ventilation, mean airway pressure, and oxygen saturation ranged from 0.84 to 0.97 (all P < .001). kappa = 0.41 (95% CI 0.02-0.80) for patient-triggered breaths, and kappa = 0.57 (95% CI 0.19-0.94) for breathing frequency higher than set frequency. kappa = -0.25 (95% CI -0.46 to -0.04) for need for suctioning. CONCLUSIONS: Telemedicine technology was acceptable to RTs. Telemedicine evaluations highly correlated with face-to-face for 10 of 14 aspects of standard bedside respiratory assessment. Poor correlation was noted for more complex, patient-generated parameters, highlighting the importance of further investigation incorporating a virtual stethoscope.

Pediatric Neurocritical Care: A Short Survey of Current Perceptions and Practices.

BACKGROUND: Although attention to neurologic injuries and illnesses in pediatric critical care is not new, a sub-specialized field of pediatric neurocritical care has only recently been recognized. Pediatric neurocritical care is an emerging area of clinical and investigative focus. Little is known about the prevalence of specialized pediatric neurocritical care services nor about perceptions regarding how it is impacting medical practice. This survey sought to capture perceptions about an emerging area of specialized pediatric neurocritical care among practitioners in intersecting disciplines, including pediatric intensivists, pediatric neurologits and pediatric neurosurgeons. METHODS: A web-based survey was distributed via email to members of relevant professional societies and groups. Survey responses were analyzed using descriptive statistics. Differences in responses between groups of respondents were analyzed using Chi-squared analysis where appropriate. MAIN RESULTS: Specialized clinical PNCC programs were not uncommon among the survey respondents with 20% currently having a PNCC service at their institution. Despite familiarity with this area of sub-specialization among the survey respondents, the survey did not find consensus regarding its value. Overall, 46% of respondents believed that a specialized clinical PNCC service improves the quality of care of critically ill children. Support for PNCC sub-specialization was more common among pediatric neurologists and pediatric neurosurgeons than pediatric intensivists. This survey found support across specialties for creating PNCC training pathways for both pediatric intensivists and pediatric neurologists with an interest in this specialized field. CONCLUSIONS: PNCC programs are not uncommon; however, there is not clear agreement on the optimal role or benefit of this area of practice sub-specialization. A broader dialog should be undertaken regarding the emerging practice of pediatric neurocritical care, the potential benefits and drawbacks of this partitioning of neurology and critical care medicine practice, economic and other practical factors, the organization of clinical support services, and the formalization of training and certification pathways for sub-specialization.

Association of breast arterial calcification with stroke and angiographically proven coronary artery disease: a meta-analysis.

OBJECTIVE: We conducted a meta-analysis of the current literature to deduce the strength of association between breast arterial calcification (BAC) and coronary artery disease (CAD) and/or stroke. METHODS: PubMed, Google Scholar, ClinicalTrials.gov, and Ovid were searched for English-language literature up to August 2013 using the terms "breast arterial calcification," "breast vascular calcification," "coronary artery disease," "coronary heart disease," "cardiovascular disease," "abnormal coronary angiography," and "stroke." A hand search of the reference lists of key articles was performed to supplement the literature search. Our literature search revealed 75 articles for further abstract review. Limiting our search to articles that quantitatively assessed the correlation between BAC and stroke or angiographically proven CAD, we reviewed 35 full manuscripts. Of these articles, 14 were included in the final analysis. RESULTS: We analyzed 10 cross-sectional studies (n = 3,952) with CAD as the primary outcome (diagnosed by coronary angiography). The odds ratio (95% CI) for CAD in those with BAC versus those without BAC is 3.86 (3.25-4.59) (P < 0.0001). For stroke, six cross-sectional studies were analyzed (n = 18,888). The odds ratio (95% CI) for stroke in those with BAC versus those without BAC is 1.54 (1.25-1.90) (P < 0.0001). CONCLUSIONS: These results suggest that BAC is significantly associated with both CAD and stroke. Although more prospective studies are warranted to clarify whether BAC is truly a predictor of the future development of CAD and stroke, the concept that BAC is a benign finding is waning.

Reliability of circulatory and neurologic examination by telemedicine in a pediatric intensive care unit.

OBJECTIVE: To test the hypothesis that telemedicine can reliably be used for many aspects of circulatory and neurologic examinations of children admitted to a pediatric intensive care unit (PICU). STUDY DESIGN: A prospective, randomized study in a 14-bed PICU in a tertiary care, academic-affiliated institution. Eligible patients were >2 months or <19 years of age, not involved in a concurrent study, had parents/guardian able to sign an informed consent form, were not at end-of-life, and had an attending who not only deemed them medically stable, but also felt that the study would not interrupt their care. Other than the Principal Investigator, 6 pediatric intensivists and 7 pediatric critical care fellows were eligible study providers. Two physician providers were randomly assigned to perform circulatory and neurologic examinations according to the American Heart Association/Pediatric Advanced Life Support guidelines in-person and via telemedicine. Findings were recorded on a standardized data collection form and compared. RESULTS: One hundred ten data collection forms were completed. For many aspects of the circulatory and neurologic examinations, outcomes showed substantial to perfect agreement between the in-person and telemedical care providers (kappa = 0.64-1.00). However, assessments of muscle tone had a kappa = 0.23, with a kappa = 0.37 for skin color. CONCLUSIONS: Telemedicine can reliably identify normal and abnormal findings of many aspects of circulatory and neurologic examinations in PICU patients. This finding opens the door to further studies on the use of telemedicine across other disciplines.

The social and environmental context of cross-border drug use in Mexico: findings from a mixed methods study of young injection drug users living in San Diego, CA.

The authors report the results of qualitative (n = 19) and quantitative (n = 545) interviews with young injection drug users (IDUs) in San Diego, California about their experiences using drugs in Tijuana, Mexico, and associated risks for HIV infection. Young IDUs who have ever traveled to Mexico (n = 365) used a variety of injection (54%) and noninjection (30%) drugs there and appear to be heavier users than those who have never traveled to Mexico. Sociocultural themes influencing drug use in Mexico included interactions among the purpose of travel, drug preference, and route of administration; familiarity with the border region; evolving relationships with the United States and Mexican drug markets; and the experience of crossing the U.S.-Mexico border. Interventions for IDUs in border regions need to be sensitive to the ethnicity, familiarity with the border region, and life history of participants, as well as differences in national policies that could influence drug use and risk for HIV on both sides of the border.

Establishment and results of a magnetic resonance quality assurance program for the pediatric brain tumor consortium.

RATIONALE AND OBJECTIVES: Magnetic resonance (MR) imaging is used to assess brain tumor response to therapies, and a MR quality assurance (QA) program is necessary for multicenter clinical trials employing imaging. This study was performed to determine overall variability of quantitative imaging metrics measured with the American College of Radiology (ACR) phantom among 11 sites participating in the Pediatric Brain Tumor Consortium (PBTC) Neuroimaging Center (NIC) MR QA program. MATERIALS AND METHODS: An MR QA program was implemented among 11 participating PBTC sites and quarterly evaluations of scanner performance for seven imaging metrics defined by the ACR were sought and subject to statistical evaluation over a 4.5-year period. Overall compliance with the QA program, means, standard deviations, and coefficients of variation (CV) for the quantitative imaging metrics were evaluated. RESULTS: Quantitative measures of the seven imaging metrics were generally within ACR recommended guidelines for all sites. Compliance improved as the study progressed. Intersite variabilities, as gauged by CV for slice thickness and geometric accuracy, imaging parameters that influence size or positioning measurements in tumor studies, were on the order of 10% and 1%, respectively. CONCLUSIONS: Although challenging to establish, MR QA programs within the context of PBTC multisite clinical trials when based on the ACR MR phantom program can indicate sites performing below acceptable image quality levels and establish levels of precision through instrumental variabilities that are relevant to quantitative image analyses (eg, tumor volume changes).

Vascular basis for the treatment of myocardial ischemia study: trial design and baseline characteristics.

BACKGROUND: Increased low-density lipoprotein (LDL) and oxidized LDL cholesterol levels adversely affect endothelial function in patients with stable coronary artery disease (CAD). Statin drugs are efficacious in primary and secondary prevention of clinical CAD events, but they have not been extensively studied as a treatment for ischemia during routine daily activities or during exercise, indicators of high-risk in patients with stable CAD. The purpose of the Vascular Basis for the Treatment of Myocardial Ischemia study is to determine whether aggressive lowering of LDL cholesterol level with atorvastatin, with or without supplemental antioxidant vitamins C and E, can improve endothelial function and ischemia during ambulatory electrocardiogram (AECG) monitoring and exercise treadmill testing (ETT). METHODS: Patients are eligible when they have ischemia during an ETT and AECG monitoring and when their fasting total cholesterol level is < or =250 mg/dL. Eligible patients are randomized to receive 1 of 3 treatments: intensive atorvastatin to reduce LDL cholesterol level to < or =80 mg/dL, intensive atorvastatin to reduce LDL cholesterol level to < or =80 mg/dL plus antioxidant vitamins C and E, and control of diet and low-dose lovastatin, when needed, to reduce LDL cholesterol level < or = to 130 mg/dL. Patients undergo endothelial function testing, 48-hour AECG monitoring, and ETT at randomization and at 6 and 12 months. RESULTS: A total of 300 patients have been randomized: 101 to receive atorvastatin alone, 103 to receive atorvastatin plus antioxidant vitamins, and 96 to receive placebo. Baseline characteristics are similar across treatment groups. CONCLUSIONS: The Vascular Basis study will provide important insight on the effects of aggressive management of dyslipidemia with statin drugs and antioxidant vitamins in patients with stable but high-risk CAD.