Extracorporeal life support in pediatric cardiac dysfunction

Background  

Low cardiac output (LCO) after corrective surgery remains a serious complication in pediatric congenital heart diseases (CHD). In the case of refractory LCO, extra corporeal life support (ECLS) extra corporeal membrane oxygenation (ECMO) or ventricle assist devices (VAD) is the final therapeutic option. In the present study we have reviewed the outcomes of pediatric patients after corrective surgery necessitating ECLS and compared outcomes with pediatric patients necessitating ECLS because of dilatated cardiomyopathy (DCM).     

Local tolerance and systemic safety of pegaptanib sodium in the dog and rabbit.

PURPOSE: To evaluate the local tolerance, systemic toxicity, and toxicokinetics in dogs and rabbits of pegaptanib sodium, an aptamer that targets vascular endothelial growth factor (VEGF(165)). METHODS: Dogs received biweekly, bilateral, intravitreous (IVT) injections of pegaptanib sodium for 9 months at doses of 0.3 (n = 10), 1 (n = 10), or 3 mg (n = 14); 14 control dogs received phosphate-buffered saline (PBS). In rabbits, pegaptanib sodium was administered by IVT injection biweekly for 6 months at doses of 0.2 (n = 14), 0.67 (n = 14), or 2 mg (n = 18); 18 rabbits received PBS. The systemic and ocular safety of pegaptanib sodium was assessed. Assessments in both dogs and rabbits included complete ophthalmologic examinations, serum chemistry, hematology, urinalysis, and coagulation assessments, as well as gross and microscopic pathologic examination. In addition, dogs were assessed by electroretinography and electrocardiography. In a cardiovascular safety study, loading intravenous boluses and maintenance infusions of pegaptanib sodium or PBS were administered to dogs (n = 4) in an ascending dose design, with each dose level separated by 2-3 days. The pegaptanib dosing regimens were designed to achieve pegaptanib plasma concentrations of approximately 90, 270, or 900 ng/mL. RESULTS: There were no pegaptanib sodium-associated clinical, ophthalmologic, pathologic, or cardiovascular abnormalities at doses of pegaptanib that achieved systemic and ocular exposure levels in excess of those associated with the recommended pegaptanib IVT dosing regimen of 0.3 mg per study eye in patients with age-related macular degeneration. CONCLUSION: These studies, together with data from clinical trials, provide strong evidence that inhibition of VEGF(165) by pegaptanib in the eye is a safe therapy for the treatment of ocular neovascular disease.     

Variations in risk-adjusted cesarean delivery rates according to race and health insurance

OBJECTIVE: To assess the association between race and insurance and Cesarean delivery rates after adjusting for clinical risk factors that increase the likelihood of cesarean delivery. DESIGN: Retrospective cohort study in 21 hospitals in northeast Ohio. SUBJECTS: 25,697 women without prior cesarean deliveries admitted for labor and delivery January 1993 through June 1995. METHODS: Demographic and clinical data were abstracted from patients' medical records. The risk of cesarean delivery was adjusted for 39 maternal and neonatal risk factors that were included in a previously developed risk-adjustment model using nested logistic regression analysis. MAIN OUTCOME MEASURES: Odds ratios for cesarean delivery in nonwhite patients relative to whites and for patients with government insurance or who were uninsured relative to patients with commercial insurance. RESULTS: The overall rate of cesarean delivery was similar in white and nonwhite patients (15.8% and 16.1%, respectively), but rates varied (P < 0.001) according to insurance (17.0%, 14.2%, 10.7% in patients with commercial insurance, government insurance, and without insurance, respectively). However, after adjusting for clinical factors, the adjusted odds ratio (OR) of cesarean delivery was higher in nonwhite patients (OR = 1.34; 95% CI: 1.14-1.57; P < 0.001), but similar for patients with government insurance (OR = 1.01; 95% CI: 0.90-1.14; P = 0.84) and lower for uninsured patients (OR = 0.65; 95% CI, 0.41, 1.03; P = 0.067), albeit not statistically significant. In analyses stratified according to quintiles of predicted risk of cesarean delivery, racial differences were largely limited to patients in the lower risk quintiles. However, differences in odds ratios for uninsured patients were seen across the risk quintiles, although odds ratios were not statistically significant. CONCLUSION: After adjusting for clinical factors, race and insurance status may independently influence the use of cesarean delivery. The higher rates in nonwhites and lower rates in the uninsured may reflect differences in patient preferences or expectations, differences in physician practice, or unmeasured risk factors. The lower odds of cesarean delivery in uninsured women, particularly women at high risk, may raise the issue of underutilization of services and warrants further study.     

A curriculum for training quality scholars to improve the health and health care of veterans and the community at large

In 1998, the Veterans Health Administration invested in the creation of the Veterans Administration National Quality Scholars Fellowship Program (VAQS) to train physicians in new ways to improve the quality of health care. We describe the curriculum for this program and the lessons learned from our experience to date. The VAQS Fellowship program has developed a core improvement curriculum to train postresidency physicians in the scholarship, research, and teaching of the improvement of health care. The curriculum covers seven domains of knowledge related to improvement: health care as a process; variation and measurement; customer/beneficiary knowledge; leading, following, and making changes in health care; collaboration; social context and accountability; and developing new, locally useful knowledge. We combine specific knowledge about the improvement of health care with the use of adult learning strategies, interactive video, and development of learner competencies. Our program provides insights for medical education to better prepare physicians to participate in and lead the improvement of health care.     

Giggle incontinence in children: a manifestation of detrusor instability

PURPOSE: To our knowledge the prevalence and cause of giggle incontinence in children is not known. We hypothesized that laughter may induce unstable detrusor contractions in children susceptible to detrusor instability. We evaluated the prevalence of diurnal voiding symptoms of urinary urgency, urge incontinence, pelvic withholding maneuvers and hesitancy in patients with giggle incontinence, the prevalence of giggle incontinence in patients with diurnal voiding symptoms, the prevalence of the 2 conditions in first degree relatives of patients with giggle incontinence, the influence of treatment for detrusor instability on the frequency of giggle incontinence and the prevalence of diurnal voiding symptoms in control children with giggle incontinence. MATERIALS AND METHODS: Of 1,421 children 5 to 15 years old referred to the pediatric nephrology department for various problems 109 were diagnosed with giggle incontinence and 460 had diurnal voiding symptoms. A total of 627 children visiting the pediatrician office whose parents completed a survey questionnaire served as controls. RESULTS: Diurnal voiding symptoms were noted in 95% of the patients with giggle incontinence, while giggle incontinence was noted in 23% of those with diurnal voiding symptoms. Of the patients with giggle incontinence a positive family history for that entity and diurnal voiding symptoms was noted in 13% and 28%, respectively. Giggle incontinence improved in all patients after treatment for detrusor instability and it resolved completely in 89%. Giggle incontinence recurred with a relapse of diurnal voiding symptoms in 28 cases and improved with improved diurnal voiding symptoms during modification of therapy. Diurnal voiding symptoms were present in 43% of the 157 controls with giggle incontinence. CONCLUSIONS: Giggle incontinence results from detrusor instability induced by laughter and it improves with effective treatment of detrusor instability.