How many child deaths can we prevent this year?

This is the second of five papers in the child survival series. The first focused on continuing high rates of child mortality (over 10 million each year) from preventable causes: diarrhoea, pneumonia, measles, malaria, HIV/AIDS, the underlying cause of undernutrition, and a small group of causes leading to neonatal deaths. We review child survival interventions feasible for delivery at high coverage in low-income settings, and classify these as level 1 (sufficient evidence of effect), level 2 (limited evidence), or level 3 (inadequate evidence). Our results show that at least one level-1 intervention is available for preventing or treating each main cause of death among children younger than 5 years, apart from birth asphyxia, for which a level-2 intervention is available. There is also limited evidence for several other interventions. However, global coverage for most interventions is below 50%. If level 1 or 2 interventions were universally available, 63% of child deaths could be prevented. These findings show that the interventions needed to achieve the millennium development goal of reducing child mortality by two-thirds by 2015 are available, but that they are not being delivered to the mothers and children who need them.     

Periocular reconstruction

The periocular area is a complex region with free margins and cosmetic landmarks that are easily distorted during surgical reconstruction. Repair of surgical defects should maintain both periorbital function and aesthetics. In this article we discuss the basic methods of closure (side-to-side closure, flaps, grafts and second intent healing) as they apply to the periocular area and suggest an algorhythmic approach to reconstruction by aesthetic subunit. Pertinent regional anatomy and perioperative management are also reviewed.     

Forestadent Young Specialist Prize (1999)

This paper describes the clinical orthodontic treatment of the three cases that were awarded the 1999 Forestadent Young Specialist Prize. There are two Class II division 1 cases treated by different treatment modalities and a Class II division 2 case complicated by a palatally ectopic maxillary canine. These case reports demonstrate the three main treatment modalities available to the orthodontist for treating skeletally-based malocclusions, i.e. growth modification, orthodontic camouflage, and a combined surgical-orthodontic approach.     

Correlations between preprocedure mood and clinical outcome in patients undergoing coronary angioplasty

We studied the relationship between mood and mood shift immediately before percutaneous coronary intervention (PCI) and 3 end points: total ischemic burden during PCI, adverse cardiac end points (ACE) after PCI, and death by 6-month follow up. Patients (n = 119) with unstable angina or myocardial infarction completed a visual analog scale (VAS) twice before PCI; before and after a session of stress relaxation, imagery, or touch; or approximately 30 minutes apart for patients assigned to prayer or to standard care. VAS included happiness, satisfaction, calm, hope, worry, shortness of breath, fear, and sadness. We observed a significant correlation between higher hope score before PCI and lower ischemic burden. Patients who experienced ACE had significantly lower hope and happiness scores than those who did not. Patients who survived to 6 months had significantly greater increases in worry and in hope. Our data suggest correlations between simple mood assessments before PCI and clinical outcomes during and after the procedure. More study is needed to understand whether attempts to alter patient mood can affect clinical outcomes.     

Effectiveness of medical resident education in mechanical ventilation

Specific methods of mechanical ventilation management reduce mortality and lower health care costs. However, in the face of a predicted deficit of intensivists, it is unclear whether residency programs are training internists to provide effective care for patients who require mechanical ventilation. To evaluate these educational outcomes, we administered a validated 19-item case-based test and survey to resident physicians at 31 diverse U.S. internal medicine residency programs nationwide. Of 347 senior residents, 259 (75%) responded. The mean test score was 74% correct (SD, 14%; range, 37 to 100%). Important items representing evidence-based standards of critical care answered incorrectly were as follows: use of appropriate tidal volume in the acute respiratory distress syndrome (48% incorrect), identifying a patient ready for a weaning trial (38% incorrect), and recognizing indication for noninvasive ventilation (27% incorrect). Most accurately identified pneumothorax (86% correct) and increased intrathoracic positive end-expiratory pressure (93% correct). Better scores were associated with "closed" versus "open" intensive care unit organization (76 versus 71% correct, p = 0.001), resident perception of greater versus lesser ventilator knowledge (79 versus 71% correct, p = 0.001), and graduation from a U.S. versus international medical school (75 versus 69% correct, p = 0.033). Although overall training satisfaction correlated strongly with program use of learning objectives (r = 0.89, p < 0.0001), only 46% reported being satisfied with their mechanical ventilation training. We conclude that senior residents may not be gaining essential evidence-based knowledge needed to provide effective care for patients who require mechanical ventilation. Residency programs should emphasize evidence-based learning objectives to guide mechanical ventilation instruction.