Practice Variation and Resource Use in the Evaluation of Pediatric Vasovagal Syncope: Are Pediatric Cardiologists Over-Testing?

Syncope is a common problem in children and adolescents. Usually vasovagal in etiology, this benign problem often results in considerable testing and expense. We sought to define the current practice, practice variation, and resource utilization as well as evaluate a screening strategy for syncope at an academic tertiary care center. We reviewed the medical records of all patients age 8 to 19 years who presented with syncope between January 1994 and January 2012 and collected data regarding demographics, history, physical examination, and diagnostic tests. Practice variation was evaluated based on provider experience and subspecialty. The sensitivity and specificity of history, physical examination, and electrocardiogram (ECG) to identify a cardiac cause for syncope were calculated. Of the 617 patients studied, a cardiac cause for syncope was found in 15 (2 %). A screening strategy consisting of history, physical examination, and ECG was 100 % sensitive and 55 % specific for diagnosing a cardiac cause for syncope. Despite having a negative screen, 314 (54 %) patients had a total of 334 additional tests at an average charge of $983/patient. Although practice variation existed, it was not explained by provider experience or electrophysiology training. Factors associated with increased testing included greater number of clinic visits and increased frequency of events, whereas those associated with decreased testing included increased number of syncopal episodes and history of psychiatric medication use. A more standardized approach to syncope is needed to decrease resource use and cost while maintaining quality of care.     

Stakeholder Perspectives in Anticipation of Sharing Physicians’ Notes With Parents of Hospitalized Children

ObjectiveElicit stakeholder perspectives on the anticipated benefits and challenges of sharing hospital physicians’ admission and daily progress notes with parents at the bedside during their child's hospitalization and identify strategies to aid implementation of inpatient note sharing.MethodsFive semistructured focus groups were conducted with 34 stakeholders (8 parents, 8 nurses, 5 residents, 7 hospitalists, 6 administrators) at a tertiary children's hospital from October to November 2018 to identify anticipated benefits, challenges, and implementation strategies prior to sharing inpatient physicians’ notes. A facilitator guide elicited participants’ perspectives about the idea of sharing notes with parents during their child's hospitalization. Three researchers used content analysis to analyze qualitative data inductively.ResultsAnticipated benefits of sharing inpatient notes included: Reinforcement of information, improved parental knowledge and empowerment, enhanced parent communication and partnership with providers, and increased provider accountability and documentation quality. Expected challenges included: Increased provider workload, heightened parental confusion, distress or anxiety, impaired parent relationship with providers, and compromised note quality and purpose. Suggested implementation strategies included: Setting staff and parent expectations upfront, providing tools to support parent education, and limiting shared note content and family eligibility.ConclusionsStakeholders anticipated multiple benefits and drawbacks of sharing notes with parents during their child's hospital stay and made practical suggestions for ways to implement inpatient note sharing to promote these benefits and mitigate challenges. Findings will inform the design and implementation of an intervention to share notes using an inpatient portal and evaluation of its effect on child, parent, and healthcare team outcomes.     

‘Quality of Life’ of Parents of Children Suffering from Pediatric Malignancies in a Low Income Setting

Objectives

To evaluate the impact of pediatric malignancies on quality of life (QOL) and psychological status of parents and to correlate it with well-matched controls and socioeconomic status.

Methods

A prospective comparative cross-sectional study was conducted. Seventy parents of children diagnosed with pediatric malignancies within the last three months were enrolled in the study group (SG) and 50 matched parents of healthy children as the control group (CG). Assessment was done by WHOQOL-BREF questionnaire, Depression Anxiety Stress Score (DASS) scale and Kuppuswamy scale. Data analysis was done by using Statistical Package for social sciences (SPSS) version 20.0. p value <0.05 considered as significant.

Results

Mean score of QOL for SG in physical health domain (D1), psychological health (D2), social relationships (D3) and environment health (D4) was 48.64, 43.07, 47.36, and 40.58 respectively whereas that of CG was 79.38, 76.32, 80.58 and 72.86 respectively and the difference was statistically significant (p value <0.001). The environmental domain (D4) had the lowest mean score amongst all domains in the SG. QOL was maximally affected by the parameter sleep, depression, personal relationship and lack of information in the respective domains. Mean depression, anxiety and stress score of SG was 23.43, 20.33, 23.56 respectively whereas that of the CG was 7.1, 8.06 and 8.54 respectively and this was statistically significant (p value <0.001). The QOL of SG in D1 for the lower socioeconomic class was 48.86 and for the upper class was 63 and this difference was statistically significant (p value <0.015). Similarly in D2 and D4 the QOL scores went higher with the socioeconomic class and this was statistically significant (p value < 0.007 and p value <0.030 respectively).

Conclusions

SG had poorer QOL and were significantly more depressed, anxious and stressed. It is concluded that effective interventions are needed to aid these families to improve outcomes by delivering the benefit of vastly improved therapeutic strategies in this field.

     

Addressing Goals of Parents of Hospitalized Children: A Qualitative Analysis of Parents’ and Physicians’ Perspectives

ObjectiveGoals of care discussions are crucial in helping parents navigate complex medical decisions and shown to improve quality of care. Little is known about whether physicians elicit or address parents’ goals during a child's hospitalization. The purpose of this study was to understand the current practice of goal setting at the beginning of hospitalization by exploring the perspectives of parents of hospitalized children and their hospital physicians.MethodsA qualitative study with semi-structured interviews was conducted from 2018 to 2019 at a 361-bed quaternary suburban freestanding children's hospital. Twenty-seven parents of hospitalized children and 16 pediatric hospital medicine faculty were matched to participate. Data were analyzed using modified grounded theory, with themes identified through constant comparative approach.ResultsFive themes were identified: 1) Majority of hospitalized children's parents want to share their goals with physicians. 2) Parents and physicians share the same underlying goal of getting the child better to go home. 3) Parents of children with chronic diseases identified nonhospital goals that were not addressed. 4) Physicians do not explicitly elicit but rather assume what parents’ goals of care are. 5) Factors related to patient, parent, and physician were identified as barriers to goal setting.ConclusionsPhysicians may not consistently elicit parents’ goals of care for their hospitalized children at the start of hospitalization. Parents desire their physicians to explicitly ask about their goals and involve them in goal setting during hospitalization. Strategies were identified by parents and physicians to improve goal setting with parents of hospitalized children.     

A Comparative Study on Children’s Rights Awareness in 16 Countries

Children’s ability to influence their own lives begins with awareness and knowledge of their rights. This ability is then strengthened with the perception that their rights are respected. Identifying the factors that affect these components of rights acquisition is crucial to promote children’s agency and growth into active citizenship. This article details a study on 8-year-old children’s understanding of their rights and their opinions about respect for their rights in 16 countries using the International Survey of Children’s Well-Being (ISCWeB). Multivariate linear regression models were constructed to study the correlates of children’s rights outcomes. Within the study sample (N = 17.369), a minority of the children were aware of children’s rights and knew about the rights they had. However, the majority of the children felt that their rights were respected. Children’s responses showed great variation by country in every dimension of the investigated rights. Depending on the country, children’s rights outcomes were most powerfully explained by three indicators: family deprivation and home and school climates. The lower the deprivation score was and the stronger the perceptions of being heard at home and school were, the more aware children were, the more knowledge they had, and the more respect for children’s rights from adults they perceived.     

Is My Kid Out of Size? Indian Mothers’ Desirability Bias in Evaluation of Their Children’s Weight

Objective

To quantify mothers’ social desirability bias with respect to their children’s weight in a cross-regional Indian setting.

Methods

The OBEY-AD was a cross-sectional study which has been realized in 7 Indian cities (Bengaluru, Mumbai, Chennai, Hyderabad, Kolkata, New Delhi and Surat), enroling 1,680 children aged 3–11 y of which 50 % were females. Children’s BMI scores were computed, standardized according to WHO growth charts and categorized as Normal, Overweight, Obese and Underweight. Mothers were asked to judge the weight status of their children through an iconographic test, indicating the shape, which better mirrors the size of their kids. Socio-demographic data, especially employment, income and education, was accessed by administrating a cross-sectional questionnaire to the mothers, involved for the study.

Results

Overall, 369 children resulted as obese or overweight (23.5 %). Out of them, 75 % (278) were not recognized as such by their mothers. Such figures range from up to 76 % in Chennai and Surat down to 72 % in Hyderabad, Kolkata, New Delhi and Mumbai. Overall agreement between perceived and desired weight status of children was very poor (p?<?0.001). Surprisingly, overall 10 % of overweight/obese children were considered as even too lean by their mothers.Misperception of children’s weight status seemed to be significantly related to urban differences and socio-economic status.

Conclusions

This study quantifies the extent of the so-called social desirability bias, namely mother’s unconscious attitude to adapt empirical evidence to more culturally legitimized ideal-types of what their children’s weight status is expected to be. Its association with westernized representations of leanness as evaluation criteria for beauty has important policy implications.

     

Inter-Rater and Test–Retest Reliability of the German Pediatric Evaluation of Disability Inventory (PEDI-G)

ABSTRACT

Activities of daily living (ADL) of children are widely assessed with the Pediatric Evaluation Disability Inventory (PEDI). This study examined test–retest and inter-rater reliability of the German PEDI (PEDI-G). During the adaptation of the PEDI nine items were added. In total, 117 parents of 53 children without and 64 children with a diagnosed physical disability from Austria, Germany, and Switzerland participated. Reliability was examined by intraclass correlation coefficient (ICC), standard error of measurement (SEM) and smallest detectable difference (SDD) for the Functional Skill Scale with and without added items and the Caregiver Assistance Scale. Cohen`s Kappa was used to calculate the reliability of the Modification Scale. All ICC's for test–retest and inter-rater reliability were above 0.75, indicating good to very good reliability. The SDD varied from 0.83–5.58 across PEDI domains and scales. For the Modification Scale, Cohen's weighted kappa varied from 0.25 to 1.00 indicating sufficient reliability for some but not all items. Our findings indicate that the Functional Skill Scale and the Caregiver Assistance Scale of the PEDI-G are reliable scales that can be used to evaluate ADLs of children with and without physical disability.     

Pediatric tonsillopharyngitis — an evaluation of cefprozil in Indian patients

Objective : The emergence of penicillin resistant strains and the presence of co-pathogens have made the treatment of bacterial infections in children a challenge. Streptococcal tonsillopharyngitis, which is a common infection has been well treated with cefprozil, a novel third generation cephalosporin. The aim of the present study was to evaluate cefprozil in pediatric tonsillopharyngitis. An assessment of the clinical cure and bacteriological eradication rates and an overall tolerability was made.Methods : It was a prospective, open, non-comparative multicentric study. 316 children (mean age 6.61 years) with tonsillopharyngitis were included. Patients were given cefprozil susp 15 mg/kg/day in two divided doses a day for 10 days.Results : A clinical cure of 96.6% and bacteriological eradication of 94.29% was achieved with cefprozil. Overall tolerability of cefprozil was assessed by physicians and 46% rated tolerability of cefprozil as excellent, 38% as very good, 10% as good, 6% as fair and none as poor.Conclusion : Cefprozil has been found to be an excellent drug of superior microbiological and clinical activity in the treatment of pediatric patients with tonsillopharyngitis. The drug also has an expanded spectrum.     

Efficacy and Safety of Deferasirox in β-Thalassemia Major Patients in Iran: A Prospective Study from a Single referral Center in Iran

Introduction: Herein, the results of a prospective study evaluating the efficacy and safety of treatment with deferasirox are studied in iron-overloaded patients with β-thalassemia major during an 18-month trial. Methods: Thirty patients who were previously chelated with deferoxamine with/without deferiprone, and fulfilled the inclusion criteria were recruited. Patients received an initial dose of 10–30 mg/kg/day. Liver and cardiac MRI T2* were evaluated before and after the trial. In addition, serum ferritin level was assessed every 3 months. Primary endpoint was regarded as significant improvement in the severity of liver and cardiac iron overload in severe and moderate cases, in addition to improvement or maintenance of the grade of severity in patients with mild iron overload or normal iron accumulation. Therapy was considered effective if primary endpoint was met in >50%. Results: Liver MRI values improved significantly (P = .002), achieving a 73.33% success rate. A successful outcome regarding myocardial iron overload was observed in 80%. Finally, an overall of 66.66% of patients met the success criteria. Secondary endpoint, regarded as safety and tolerability was reached by 93.33%. The most common adverse events were skin rash and gastrointestinal disturbance. A dose between 30 and 40 mg/kg/day, tailored to each patient was considered the optimal dose. Conclusion: Deferasirox proved as an efficient and safe chelating agent in our patients, specifically in mild to moderate iron overloaded patients.