The PedsQL in pediatric rheumatology: reliability, validity, and responsiveness of the Pediatric Quality of Life Inventory Generic Core Scales and Rheumatology Module

OBJECTIVE: The Pediatric Quality of Life Inventory (PedsQL) is a modular instrument designed to measure health-related quality of life (HRQOL) in children and adolescents ages 2-18 years. The 23-item PedsQL 4.0 Generic Core Scales are multidimensional child self-report and parent proxy-report scales developed as the generic core measure to be integrated with the PedsQL disease-specific modules. The 22-item PedsQL 3.0 Rheumatology Module was designed to measure pediatric rheumatology-specific HRQOL. This study was undertaken to demonstrate the reliability, validity, and responsiveness of the PedsQL 4.0 Generic Core Scales and the PedsQL 3.0 Rheumatology Module in pediatric rheumatology. METHODS: The 4 PedsQL 4.0 Generic Core Scales (physical, emotional, social, and school functioning) and the 5 PedsQL 3.0 Rheumatology Module scales (pain and hurt, daily activities, treatment, worry, and communication) were administered to 231 children and 244 parents (271 subjects accrued overall) recruited from a pediatric rheumatology clinic. RESULTS: Internal consistency reliability for the PedsQL Generic Core total scale score (alpha = 0.91 for child self report, alpha = 0.93 for parent proxy report), physical health summary score (alpha = 0.87 for child self report, alpha = 0.89 for parent proxy report), and psychosocial health summary score (alpha = 0.86 for child self report, alpha = 0.90 for parent proxy report) were acceptable for group comparisons. The Rheumatology Module scales also demonstrated acceptable reliability for group comparisons (alpha = 0.75-0.86 for child self report, alpha = 0.82-0.91 for parent proxy report). Validity was demonstrated using the known-groups method. The PedsQL distinguished between healthy children and children with rheumatic diseases as a group. The responsiveness of the PedsQL was demonstrated through patient change over time as a result of clinical intervention. CONCLUSION: The results demonstrate the reliability, validity, and responsiveness of the PedsQL 4.0 Generic Core Scales and the PedsQL 3.0 Rheumatology Module in pediatric rheumatology.     

Cefdinir-Induced Hepatotoxicity: Potential Hazards of Inappropriate Antibiotic Use

Drug-induced hepatotoxicity is well recognized but can cause some diagnostic problems, particularly if not previously reported. The present case involves a 22-year-old male who presented with jaundice and elevated liver enzymes after a course of cefdinir (Omnicef) for streptococcal pharyngitis. A diagnosis of drug-induced liver injury was suspected but a liver biopsy was required after his jaundice worsened despite cessation of the presumed offending agent. A short course of steroids was initiated and eventually the jaundice resolved. This case highlights the need to suspect medication-induced liver injury in cases of jaundice, even if not previously reported. In addition, it illustrates the potential for adverse outcomes in situations where antibiotics are used inappropriately or where first line antibiotics are not used for routine infections. We report a case of a young male who developed jaundice associated with cefdinir use with pathological confirmation of moderate cholestasis with portal and lobular mixed inflammation and focal bile duct injury consistent with drug-induced liver injury.     

Structured behavioral intervention to increase children's adherence to treatment for latent tuberculosis infection.

SETTING: San Diego, California public health department tuberculosis clinic. OBJECTIVE: To evaluate the effectiveness of a behavioral intervention (the Treasure Chest) that employed the behavior modification techniques of self-monitoring and positive reinforcement to increase adherence to therapy for latent tuberculosis infection (LTBI) in children. DESIGN: A retrospective study utilizing a historical comparison group. The treatment adherence of children who attended San Diego County TB Control Program (SDCTBCP) clinics with positive tuberculin skin tests who were started on LTBI treatment prior to Treasure Chest program implementation (n=841) was compared to that of SDCTBCP children enrolled in the Treasure Chest program (n=741). RESULTS: Logistic regression analysis demonstrated that children who participated in the Treasure Chest program were 2.4 times more likely to complete therapy than those who did not receive the intervention. CONCLUSION: The Treasure Chest intervention is effective in increasing adherence to LTBI therapy in children.     

Lung inflammation induced by concentrated ambient air particles is related to particle composition

The objectives of this study were (1) to determine whether short-term exposures to concentrated air particles (CAPs) cause pulmonary inflammation in normal rats and rats with chronic bronchitis (CB); (2) to identify the site within the lung parenchyma where CAPs-induced inflammation occurs; and (3) to characterize the component(s) of CAPs that is significantly associated with the development of the inflammatory reaction. Four groups of animals were studied: (1) air treated, filtered air exposed (air-sham); (2) sulfur dioxide treated (CB), filtered air exposed (CB-sham); (3) air treated, CAPs exposed (air-CAPs); and (4) sulfur dioxide treated, CAPs exposed (CB-CAPs). CB and normal rats were exposed by inhalation either to filtered air or CAPs during 3 consecutive days (5 hours/day). Pulmonary inflammation was assessed by bronchoalveolar lavage (BAL) and by measuring the numerical density of neutrophils (Nn) in the alveolar walls at the bronchoalveolar junction and in more peripheral alveoli. CAPs (as a binary exposure term) and CAPs mass (in regression correlations) induced a significant increase in BAL neutrophils and in normal and CB animals. Nn in the lung tissue significantly increased with CAPs in normal animals only. Greater Nn was observed in the central compared with peripheral regions of the lung. A significant dose-dependent association was found between many CAPs components and BAL neutrophils or lymphocytes, but only vanadium and bromine concentrations had significant associations with both BAL neutrophils and Nn in CAPs-exposed groups analyzed together. Results demonstrate that short-term exposures to CAPs from Boston induce a significant inflammatory reaction in rat lungs, with this reaction influenced by particle composition.     

The effect of providing fansidar (sulfadoxine-pyrimethamine) in schools on mortality in school-age children in Malawi

Malaria is a major cause of death in school-age (5-18 years) children in Malawi. Save the Children Federation helped schools in Mangochi District, Malawi, to obtain pupil-treatment kits, which enabled teachers to dispense sulfadoxine-pyrimethamine tablets according to national guidelines. The overall and malaria-specific mortality rates were calculated for the 3 years before and 2 years after the intervention was introduced; rates dropped from 2.2 to 1.44 deaths/1000 student-years and from 1.28 to 0.44 deaths/1000 student-years, respectively. School-based interventions could play a part in mitigating malaria.     

Hemolytic Anemia Associated with the Use of Omeprazole

Omeprazole is the first drug designed to block the final step in the acid secretory process within the parietal cell. It has been shown to be extremely effective in the treatment of peptic ulcer disease, reflux esophagitis, and the Zollinger-Ellison syndrome. Although clinical experience with omeprazole is still limited, many controlled studies have established the short-term safety of this drug. We report the first case of a serious short-term adverse reaction with the use of omeprazole: hemolytic anemia. The patient developed weakness, lethargy, and shortness of breath 2 days after starting therapy with omeprazole. Two weeks after the initiation of therapy, her hematocrit had decreased from 44.1% to 20.4%, and she had a positive direct Coombs antiglobulin test and an elevated indirect bilirubin. After she discontinued the omeprazole, her hemoglobin and hematocrit gradually returned to normal. The mechanism by which omeprazole caused the patient's hemolytic anemia is uncertain, but physicians should be alerted to this possible adverse effect.     

Hormone-sensitive lipase in differentiated 3T3-L1 cells and its activation by cyclic AMP-dependent protein kinase

Differentiation of 3T3-L1 fibroblasts to adipocyte-like cells was accompanied by a 19-fold increase in neutral triglyceride lipase activity, a 12-fold increase in diglyceride lipase activity, a 10-fold increase in monoglyceride lipase activity, and a 280-fold increase in cholesterol esterase activity. In contrast, acid acylhydrolase activities did not increase during differentiation. The rate of glycerol release from unstimulated intact cells increased by more than 1 order of magnitude upon differentiation. Isoproterenol (1 microM) and 1-methyl-3-isobutylxanthine (0.1 mM) further stimulated this rate of glycerol release 3-fold. The neutral triglyceride lipase activity in cell-free preparations of differentiated cells was activated 105% by cyclic AMP-dependent protein kinase. Neutral cholesterol esterase, diglyceride lipase, and monoglyceride lipase were also activated (117%, 10%, and 37+, respectively) by cyclic AMP-dependent protein kinase. In contrast, protein kinase had no effect on any of the four lysosomal acid acylhydrolase activities. Thus, hormone-sensitive lipase, the most characteristic and functionally important enzyme of adipose tissue, has been characterized in differentiated 3T3-L1 cells. The 3T3-L1 cell should be a valuable model system in which to study regulation of hormone-sensitive lipase, particularly its long-term regulation.     

Reduction in treatment delay by paramedic ECG diagnosis of myocardial infarction with direct CCU admission

Objectives—To establish the feasibility of training paramedics to diagnose acute myocardial infarction by ECG before hospital admission and whether direct paramedic coronary care admission, arranged by very high frequency (VHF) radio communication with the coronary care unit (CCU), would reduce delay of thrombolysis treatment.
Design—Prospective controlled study.
Setting—District general hospital CCU and a local district ambulance paramedic service.
Patients—124 patients with ECG evidence of myocardial infarction or ischaemia admitted directly to the CCU by the paramedic service were compared with 123 patients admitted by the emergency department and subsequently transferred to the CCU.
Main outcome measures—ECG diagnostic accuracy by paramedics, and interval durations for CCU admission and thrombolysis.
Results—ECG diagnostic accuracy by the paramedics was 87.5% in the training phase and 92% in admission. The total call to thrombolysis interval was reduced from 154 to 93 minutes and the "door to needle" interval was reduced from 97 to 37 minutes.
Conclusions—Trained paramedics can reliably diagnose myocardial infarction by ECG. The use of a direct admission procedure, by a VHF radio link to the CCU, substantially reduces the time interval for thrombolytic treatment after acute myocardial infarction.

Keywords: myocardial infarction;  electrocardiogram;  thrombolysis;  paramedic