Protocolized management of infants with congenital diaphragmatic hernia: effect on survival

Background/Purpose

In 2006, we introduced a new protocol for congenital diaphragmatic hernia (CDH) management featuring nitric oxide in the delivery room, gentle ventilation, lower criteria for extracorporeal membrane oxygenation (ECMO), and appropriately timed operative repair on ECMO. Our goals were to assess outcomes after institution of this protocol and to compare results with historical controls.

Methods

Charts were reviewed of all newborns admitted to a large metropolitan children's hospital from 2002 to 2009 with a diagnosis of CDH. Data were recorded regarding delivery, ECMO, operative repair, length of stay, comorbidities/anomalies, complications, and survival. Postprotocol outcomes were compared to those from the preprotocol era and to data from the international CDH Registry.

Results

Comparison of the protocolized group (n = 43) to the historical group (n = 51) revealed no significant differences in gestational age, birth weight, Apgar scores, or comorbidities. New treatment strategies substantially improved survival to discharge (67% preprotocol, 88% postprotocol; P = .015). Among ECMO patients, survival increased to 82% (20% preprotocol; P = .002).

Conclusions

Our new protocol significantly improved survival to discharge for newborns with CDH. Institution of such a protocol is valuable in improving outcomes for patients with CDH and merits consideration for widespread adoption.     

A randomised control trial of the effectiveness of personalised letters sent subsequent to school dental inspections in increasing registration in unregistered children

Background

The Child Perceptions Questionnaires (CPQ_8–10 and CPQ_11–14) are indicators of child oral health-related quality of life. The aim of this study was to assess the validity and reliability of the self-applied CPQ_8–10 and CPQ_11–14 in Brazilian children, after translations and cultural adaptations in the Brazilian Portuguese language.

Methods

Schoolchildren were recruited from general populations for pre-testing (n = 80), validity (n = 210), and test-retest reliability (n = 50) studies. They were also examined for dental caries, gingivitis, fluorosis, and malocclusion.

Results

Children with greater dental caries experience in primary dentition had higher impacts on CPQ domains. Girls had higher scores for CPQ_8–10 domains than boys. Mean CPQ_11–14 scores were highest for 11-year-old children and lowest for 14-year-old children. Construct validity was supported by significant associations between the CPQ_8–10 and CPQ_11–14 scores and the global rating of oral health (r = 0.38, r = 0.43) and overall well-being (r = 0.39, r = 0.60), respectively. The Cronbach's alpha was 0.95 for both questionnaires. The test-retest reliabilities of the overall CPQ_8–10 and CPQ_11–14 scores were both excellent (ICC = 0.96, ICC = 0.92).

Conclusion

The Brazilian Portuguese version of CPQ_8–10 and CPQ_11–14 was valuable and reliable for use in the Brazilian child population, although discriminant validity was sporadic due to the fact that impacts are mediated by others factors, such personal, social, and environmental variables.     

患者的权利

许多人都知道,有一个患者权利法案,但大多数患者不知道他们的权利。许多人只是按照医生告诉他们的去做。一些人甚至不问为什么。许多人不问为什么是因为他们不想耽误医生或护士的时间,或者可能缺少医疗知识,一些人甚至不知道要问些什么问题。护士们应该确信患者和家属知道他们的权利。美国医院协办(AHA)1973年首次起草了患者的权利法案,1992年做了修订。AHA起草这个文件的目的是为了支持那些提供最佳医护的医院和保健护理部门,但在过去只是把权利写进了文件中。这个文件也保护患者的权益。AHA建议所有的患者和保健护理部门都要知道这些…     

Causes and evaluation of mildly elevated liver transaminase levels

Mild elevations in levels of the liver enzymes alanine transaminase and aspartate transaminase are commonly discovered in asymptomatic patients in primary care. Evidence to guide the diagnostic workup is limited. If the history and physical examination do not suggest a cause, a stepwise evaluation should be initiated based on the prevalence of diseases that cause mild elevations in transaminase levels. The most common cause is nonalcoholic fatty liver disease, which can affect up to 30 percent of the population. Other common causes include alcoholic liver disease, medication-associated liver injury, viral hepatitis (hepatitis B and C), and hemochromatosis. Less common causes include α(1)-antitrypsin deficiency, autoimmune hepatitis, and Wilson disease. Extrahepatic conditions (e.g., thyroid disorders, celiac disease, hemolysis, muscle disorders) can also cause elevated liver transaminase levels. Initial testing should include a fasting lipid profile; measurement of glucose, serum iron, and ferritin; total iron-binding capacity; and hepatitis B surface antigen and hepatitis C virus antibody testing. If test results are normal, a trial of lifestyle modification with observation or further testing for less common causes is appropriate. Additional testing may include ultrasonography; measurement of α(1)-antitrypsin and ceruloplasmin; serum protein electrophoresis; and antinuclear antibody, smooth muscle antibody, and liver/kidney microsomal antibody type 1 testing. Referral for further evaluation and possible liver biopsy is recommended if transaminase levels remain elevated for six months or more.     

Model to predict mortality in critically ill adults with acute kidney injury

Summary

Background and objectives

Acute kidney injury (AKI) requiring dialysis is associated with high mortality. Most prognostic tools used to describe case complexity and to project patient outcome lack predictive accuracy when applied in patients with AKI. In this study, we developed an AKI-specific predictive model for 60-day mortality and compared the model to the performance of two generic (Sequential Organ Failure Assessment [SOFA] and Acute Physiology and Chronic Health Evaluation II [APACHE II]) scores, and a disease specific (Cleveland Clinic [CCF]) score.

Design, setting, participants, & measurements

Data from 1122 subjects enrolled in the Veterans Affairs/National Institutes of Health Acute Renal Failure Trial Network study; a multicenter randomized trial of intensive versus less intensive renal support in critically ill patients with AKI conducted between November 2003 and July 2007 at 27 VA- and university-affiliated centers.

Results

The 60-day mortality was 53%. Twenty-one independent predictors of 60-day mortality were identified. The logistic regression model exhibited good discrimination, with an area under the receiver operating characteristic (ROC) curve of 0.85 (0.83 to 0.88), and a derived integer risk score yielded a value of 0.80 (0.77 to 0.83). Existing scoring systems, including APACHE II, SOFA, and CCF, when applied to our cohort, showed relatively poor discrimination, reflected by areas under the ROC curve of 0.68 (0.64 to 0.71), 0.69 (0.66 to 0.73), and 0.65 (0.62 to 0.69), respectively.

Conclusions

Our new risk model outperformed existing generic and disease-specific scoring systems in predicting 60-day mortality in critically ill patients with AKI. The current model requires external validation before it can be applied to other patient populations.     

Inequalities in full immunization coverage: trends in low- and middle-income countries

ObjectiveTo investigate disparities in full immunization coverage across and within 86 low- and middle-income countries.MethodsIn May 2015, using data from the most recent Demographic and Health Surveys and Multiple Indicator Cluster Surveys, we investigated inequalities in full immunization coverage – i.e. one dose of bacille Calmette-Guérin vaccine, one dose of measles vaccine, three doses of vaccine against diphtheria, pertussis and tetanus and three doses of polio vaccine – in 86 low- or middle-income countries. We then investigated temporal trends in the level and inequality of such coverage in eight of the countries.FindingsIn each of the World Health Organization’s regions, it appeared that about 56–69% of eligible children in the low- and middle-income countries had received full immunization. However, within each region, the mean recorded level of such coverage varied greatly. In the African Region, for example, it varied from 11.4% in Chad to 90.3% in Rwanda. We detected pro-rich inequality in such coverage in 45 of the 83 countries for which the relevant data were available and pro-urban inequality in 35 of the 86 study countries. Among the countries in which we investigated coverage trends, Madagascar and Mozambique appeared to have made the greatest progress in improving levels of full immunization coverage over the last two decades, particularly among the poorest quintiles of their populations.ConclusionMost low- and middle-income countries are affected by pro-rich and pro-urban inequalities in full immunization coverage that are not apparent when only national mean values of such coverage are reported.     

AUTOSOMAL RECESSIVE INHERITANCE OF HYPOHIDROTIC ECTODERMAL DYSPLASIA

Letters to the Editor are welcomed for publication (subject to editing). Letters must be signed by all autliors, typewritten double spaced, and must not exceed two pages of text including references. Two copies of all letters should be submitted. Letters should not duplicate material submitted or published in other journals. Prepublication proofs will not be provided.