Differences In Severity Of Illness Research Articles

Genetic modifiers and subtypes in schizophrenia: Investigations of age at onset, severity, sex and family history

Schizophrenia is a genetically and clinically heterogeneous disorder. Genetic risk factors for the disorder may differ between the sexes or between multiply affected families compared to cases with no family history. Additionally, limited data support a genetic basis for variation in onset and severity, but specific loci have not been identified. We performed genome-wide association studies (GWAS) examining genetic influences on age at onset (AAO) and illness severity as well as specific risk by sex or family history status using up to 2762 cases and 3187 controls from the International Schizophrenia Consortium (ISC).Subjects with a family history of schizophrenia demonstrated a slightly lower average AAO that was not significant following multiple testing correction (p=.048), but no differences in illness severity were observed by family history status (p=.51). Consistent with prior reports, we observed earlier AAO (p=.005) and a more severe course of illness for men (p=.002). Family history positive analyses showed the greatest association with KIF5C (p=1.96×10−8), however, genetic risk burden overall does not differ by family history. Separate association analyses for males and females revealed no significant sex-specific associations. The top GWAS hit for AAO was near the olfactory receptor gene OR2K2 (p=1.52×10−7). Analyses of illness severity (episodic vs. continuous) implicated variation in ST18 (p=8.24×10−7). These results confirm recognized demographic relationships but do not support a simplified genetic architecture for schizophrenia subtypes based on these variables.

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Introduction: Resuscitation bundles (RB) from the Surviving Sepsis Campaign (SSC) guidelines with rapid recognition and aggressive intervention of septic shock (SS) dramatically improves outcome. Recent studies suggest that hospitals are less than 25% compliant with the suggested treatment guidelines. We examined the impact of the RB on outcomes of SS patients when completed beyond the 6-hour recommendation period. Methods: This study was completed at a large university-affiliated hospital evaluating patients with SS between July 2011 and January 2013. Data elements were prospectively collected. Compliance with the hemodynamic components of the RB was defined as achieving goal mean arterial pressure (MAP) >65 mm Hg, central venous pressure (CVP) > 8 mm Hg, and central venous oxygen saturation (ScvO2) > 70%, lactic acid measurement, and appropriate antibiotics prescribed within 3 hours. Compliance was assessed at 6 hours and 18 hours after diagnosis of SS. Septic shock patients were divided into three groups: RB compliance at 6 hours (C 6, n = 95, 24 % compliance), RB compliance between 6 and 18 hours (C 18, n = 85), and RB noncompliance at 18 hours (NC, n = 215). Primary outcome was hospital mortality. Results: The 3 groups were similar regarding the following: age in years, 67 (+/- 16) vs 67 (+/- 17) vs 68 (+/-16) (p = 0.9); weight in Kgs, 82 (+/- 28) vs 80 (+/- 23) vs 79 (+/- 28) (p=0.7); and sequential organ failure assessment (SOFA) scores, 8 (+/- 4) vs 7 (+/-3) vs 8 (+/- 4) (p=0.06) in the C6 vs C 18 vs NC groups respectively. Using Cox proportional hazard analysis and adjusting for differences in severity of illness and baseline characteristics, both C6 (hazard ration [HR] = 0.45; 95 % CI, 0.24 – 0.85, p = 0.01) and C18 (HR = 0.12; 95 % CI, 0.04 – 0.39, p < 0.001) had a reduction in mortality compared to the NC group. Conclusions: Multiple studies have shown that compliance with the RB within 6 hours lowers hospital mortality. This study demonstrates that RB compliance extended up to 18 hours confers a significant mortality reduction in patients diagnosed with septic shock.

Characteristics and outcomes of elderly patients refused to ICU.

Background. There are few data regarding the process of deciding which elderly patients are refused to ICU admission, their characteristics, and outcome. Methods. Prospective longitudinal observational cohort study. We included all consecutive patients older than 75 years, who were evaluated for admission to but were refused to treatment in ICU, during 18 months, with 12-month followup. We collected demographic data, ICU admission/refusal reasons, previous functional and cognitive status, comorbidity, severity of illness, and hospital and 12-month mortality. Results. 338 elderly patients were evaluated for ICU admission and 88 were refused to ICU (26%). Patients refused because they were “too ill to benefit” had more comorbidity and worse functional and mental situation than those admitted to ICU; there were no differences in illness severity. Hospital mortality rate of the whole study cohort was 36.3%, higher in patients “too ill to benefit” (55.6% versus 35.8%, P < 0.01), which also have higher 1-year mortality (73.7% versus 42.5%, P < 0.01). High comorbidity, low functional status, unavailable ICU beds, and age were associated with refusal decision on multivariate analysis. Conclusions. Prior functional status and comorbidity, not only the age or severity of illness, can help us more to make the right decision of admitting or refusing to ICU patients older than 75 years.

Historical Changes in the Severity of Dementia and Accompanying Neuropsychiatric Symptoms in Persons Presenting for Evaluation in a Multiracial Urban Dementia Center

We examine historical changes from 1992 to 2008 in the severity of dementia and accompanying neuropsychiatric symptoms among persons presenting for evaluation and treatment at a multiracial urban dementia center. We reviewed intakes of white (n=197) and black (n=568) patients seen at a dementia center in New York City. Intakes were divided into 3 time categories: period 1 (1992 to 1996), period 2 (1997 to 2002), and period 3 (2003 to 2008). Diagnoses included the following: Alzheimer disease (73%), vascular dementia (13%), mixed dementia (9%), mild cognitive impairment (2%), and other dementias (4%). Over the 3 assessment periods, persons increasingly presented at an earlier stage of illness with significantly higher levels of cognition and functioning, and a declining prevalence of psychotic symptoms and agitation. Blacks had a more advanced stage of illness, lower cognitive scores, and a greater prevalence of psychotic symptoms than whites in period 1, but not during the other time periods. There were no racial differences in functioning, agitation, or depression. Over the period 1992 to 2008, patients were increasingly more likely to present with early stages of dementia and fewer symptoms of psychoses and agitation, and racial differences in illness severity and neuropsychiatric symptoms disappeared. If our sample reflects trends in the United States, then it suggests that more persons will be in care for longer periods of time, previous research findings derived from dementia centers must be considered historically specific, and clinicians must be prepared to work with persons with milder forms of neurocognitive disorders.

2009 Pandemic influenza A (H1N1) in critically ill children in Cincinnati, Ohio*

To compare the clinical features, management, and outcome of critically ill children with H1N1 to children with seasonal influenza from the previous three influenza seasons. The overall number of hospitalizations and the proportion cared for in the pediatric intensive care unit during the H1N1 epidemic period and the three previous influenza seasons (2007-2009) were determined. Medical records of patients admitted to the pediatric intensive care unit with H1N1 and seasonal influenza infection were reviewed. Cincinnati Children's Hospital Medical Center, a large, 523-bed hospital located in Cincinnati. Hospitalized children with laboratory-confirmed seasonal or H1N1 infection. Study variables included demographic data (age, gender), clinical factors (weight, Pediatric Risk of Mortality III scores, presenting signs and symptoms, comorbid conditions), management (length of mechanical ventilation, other treatments, including high-frequency oscillatory ventilatory support, inhaled nitric oxide, or extracorporeal membrane oxygenation), and outcome (overall and pediatric intensive care unit length of stay and mortality). Overall, 312 children were hospitalized with H1N1 and 222 with seasonal influenza from the three previous seasons. Children with H1N1 infection were significantly less likely to require pediatric intensive care unit care compared to children with seasonal influenza infection (14% vs. 24%, p = .02). Compared to children with seasonal influenza, children in the pediatric intensive care unit with H1N1 were older (median age in months 107 vs. 68, p = .05) and significantly more likely to have comorbid conditions (64% vs. 40%, p = .03), especially respiratory conditions. While there were no significant differences in severity of illness by Pediatric Risk of Mortality III scores or pediatric intensive care unit length of stay, children with H1N1 were significantly less likely to have acute respiratory failure (p = .04) or die compared to children with seasonal influenza infection (p = .03). In contrast to other studies, we found that critically ill children with H1N1 had a significantly lower morbidity and mortality compared to children with seasonal influenza.

Efficacy of continuous blood purification on rescue therapy of the critically ill children with acute lung injury and acute respiratory distress syndrome

To investigate the efficacy of continuous blood purification(CBP) in the treatment of acute lung injury/acute respiratory distress syndrome (ALI/ARDS) in children. One hundred and forty seven cases of ALI/ARDS were hospitalized to our pediatric intensive care unit, and 32 cases were treated with continuous blood purification (CBP) from June, 2006 to May, 2011. The model for CBP was continuous veno-venous hemofiltration dialysis (CVVHDF). CBP treatment persisted for at least 8 hours and replacement + dialysis fluid dose was 35 - 100 ml/(kg·h). The clinical outcome measures included the mortality rate at 28th day, respiratory index (FiO2/PO2), dynamic lung compliance (Cdyn), arterial partial pressure of oxygen (PaO2), arterial partial pressure of carbon dioxide (PaCO2), mechanical ventilation parameters, vasoactive drug dose and lung X-ray changes. In totally 147 cases of ALI/ARDS, 89 cases (60.5%) were male and 58 (39.5%) were female, mean age was (43.4 ± 36.7) months. Death occurred in 54 cases, the total mortality was 36.7%. The cause of ALI/ARDS was mainly severe pneumonia, severe sepsis, and leukemia or tumor diseases. There were significant differences in severity of illness between the CBP treatment group and non-CBP treatment group on Pediatric risk of score mortality (PRISM) III score (15.3 vs. 12.7, P < 0.05) and pediatric critical illness score (66.8 ± 19.3 vs. 74.6 ± 17.7, P < 0.05). The average duration of CBP treatment was 52 hours (12 hours to 232 hours). PaO2/FiO2 and Cdyn were improved after 2 hours CBP treatment compared with those before CBP treatment (P < 0.05), mechanical ventilation parameters including fraction of inspired oxygen (FiO2), peak inspiratory pressure (PiP) and positive end expiratory pressure (PEEP) were reduced. The use of vasoactive drugs in patients with MODS and shock gradually declined. The average ventilator-free days of the two groups did not show significant difference (P > 0.05). The mortality on CBP treatment group and non-treatment group were 37.5% and 36.5%, respectively, the difference was not significant (P > 0.05). CBP adjuvant treatment for ALI/ ARDS could reduce pulmonary edema, improve PaO2/FiO2 and Cdyn, and improve mechanical ventilation parameters. CBP may be a very promising treatment for ALI/ARDS in children.

Delayed Acyclovir Therapy and Death Among Neonates With Herpes Simplex Virus Infection

To determine the association of delayed acyclovir therapy with death among neonates with herpes simplex virus (HSV) infection. A multicenter, retrospective, cohort study was conducted between January 1, 2003, and December 31, 2009, with 1086 neonates (age: ≤28 days) with HSV infection from 41 tertiary care children's hospitals. Early acyclovir therapy was defined as initiation of intravenous acyclovir treatment within 1 day after hospital admission, and delayed acyclovir therapy was defined as initiation of treatment >1 and ≤7 days after hospital admission. Multivariate logistic regression models determined the association between delayed acyclovir therapy and death, with the use of propensity scores for each neonate's likelihood of receiving delayed acyclovir treatment to control for differences in illness severity between groups. The median age was 10 days. Delayed acyclovir therapy was administered to 262 neonates (24.1%). In most cases (86.2%) of delayed receipt, acyclovir administration occurred on the second or third day of hospitalization. The overall mortality rate was 7.3% (95% confidence interval: 5.8%-9.0%); 9.5% of those who received delayed acyclovir treatment and 6.6% of those who received early acyclovir treatment died. In a multivariate analysis, delayed acyclovir therapy was associated with significantly greater odds of death (adjusted odds ratio: 2.63 [95% confidence interval: 1.36-5.08]) compared with early acyclovir therapy. In this multicenter observational study of neonates with HSV infection, delayed initiation of acyclovir therapy was associated with in-hospital death. Our data support the use of empiric acyclovir therapy for neonates undergoing testing for HSV infection.

Viral Etiology of Acute Febrile Respiratory Illnesses in Hospitalized Children Younger Than 24 Months

Respiratory infections are a leading cause of pediatric hospitalizations. This study investigated whether virus-virus or virus-Bordetella co-infections are more frequent or more severe than previously recognized. This is a 3-year prospective study of children younger than 24 months hospitalized with a febrile respiratory illness. Viral pathogens were detected using multiplex polymerase chain reaction (PCR), enzyme-linked immunoassays, and/or viral cultures from nasopharyngeal samples. Bordetella infections were detected by PCR. A total of 201 patients were enrolled. Respiratory viruses were detected in 187 (93%) patients, with 52 (28%) multipathogen infections. The most common viruses detected were respiratory syncytial virus and rhinovirus/enterovirus. There were no differences in illness severity when comparing patients infected with one pathogen and those with multipathogen infection. Virus co-infection in young children hospitalized with an acute febrile respiratory infection is common but does not appear to be associated with illness severity.

The Regionalization of Pediatric Health Care

Regionalization of health care is a method of providing high-quality, cost-efficient health care to the largest number of patients. Within pediatric medicine, regionalization has been undertaken in 2 areas: neonatal intensive care and pediatric trauma care. The supporting literature for the regionalization of these areas demonstrates the range of studies within this field: studies of neonatal intensive care primarily compare different levels of hospitals, whereas studies of pediatric trauma care primarily compare the impact of institutionalizing a trauma system in a single geographic region. However, neither specialty has been completely regionalized, possibly because of methodologic deficiencies in the evidence base. Research with improved study designs, controlling for differences in illness severity between different hospitals; a systems approach to regionalization studies; and measurement of parental preferences will improve the understanding of the advantages and disadvantages of regionalizing pediatric medicine and will ultimately optimize the outcomes of children.

Analysis of Consistency in Intensive Care Unit Consultants' Decision Making in Clinical Practice

This study examined whether there was significant variation in the rate at which different intensive care unit (ICU) consultants accept unplanned referrals to critical care. Over 2.75 years, 1,292 unplanned referrals were admitted to the ICU at Glan Clwyd Hospital, representing an average rate of one unplanned admission every 18.6 hours. There was significant variation in the rate at which consultants accepted unplanned referrals, ranging from 0.99 to 1.83 admissions per 24 hours (p = 0.0039). There was also a significant difference between the rate of acceptance during normal working hours and outside these hours (p <0.001). Some of this variation was associated with differences in severity of illness, whether the patient was accepted in or out of hours and the number of beds used each day. Using rates of acceptance of unplanned admissions could be a useful measure of an ICU consultant’s performance.

Procedure volume is one determinant of centre effect in mechanically ventilated patients

Survival rates vary significantly between intensive care units, most notably in patients requiring mechanical ventilation (MV). The present study sought to estimate the effect of hospital MV volume on hospital mortality. We included 179,197 consecutive patients who received mechanical ventilation in 294 hospitals. Multivariate logistic regression models with random intercepts were used to estimate the effect of annual MV volume in each hospital, adjusting for differences in severity of illness and case mix. Median annual MV volume was 162 patients (interquartile range 99-282). Hospital mortality in MV patients was 31.4% overall, 40.8% in the lowest annual volume quartile and 28.2% in the highest quartile. After adjustment for severity of illness, age, diagnosis and organ failure, higher MV volume was associated with significantly lower hospital mortality among MV patients (OR 0.9985 per 10 additional patients, 95% CI 0.9978-0.9992; p = 0.0001). A significant centre effect on hospital mortality persisted after adjustment for volume effect (p < 0.0001). Our study demonstrated higher hospital MV volume to be independently associated with increased survival among MV patients. Significant differences in outcomes persisted between centres after adjustment for hospital MV volume, supporting a role for other significant determinants of the centre effect.

The effects of critical care outreach services before and after critical care: A matched-cohort analysis

Purpose The purpose of the study was to evaluate the effect of visits from critical care outreach services (CCOS) before admission to and following discharge from critical care. Materials and Methods A cohort study was performed in 52 acute hospitals in England. A total of 23 234 patients received CCOS visits; 10 404 (45%) were admitted to a critical care unit, and 7078 (68%) were included in the analysis. Patients receiving CCOS visits before (n = 2203) and after (n = 5924) critical care were matched 1:1 to 3 control pools: historical admissions to the same unit before introduction of CCOS, admissions to a unit in a hospital with no CCOS, and contemporary admissions to the same unit not receiving CCOS visits. Matching was based on individual factors and on propensity. Results The CCOS visits preadmission were not associated with differences in severity of illness, but were associated with lower rates of cardiopulmonary resuscitation, longer prior hospital stay, and longer unit stay. The CCOS visits postdischarge were associated with lower hospital mortality and shorter hospital stay in 2 matches, but not when compared with contemporary admissions to the same unit. Conclusions Our results suggest a benefit to scheduled follow-up visits of patients discharged from critical care. Results for CCOS before critical care are inconclusive.

Ecological Studies and Cardiovascular Outcomes Research

Is it better to have a heart attack in the United States or Canada? Ecological studies are epidemiological evaluations in which the unit of analysis is populations, or groups of people, rather than individuals.1 They can answer important questions such as the question posed above that cannot easily be answered using any other form of study design. Ecological studies are conducted by researchers in a variety of disciplines, including outcomes researchers, to study potential causal associations between 1 or more exposure and outcome variables. They are frequently used where alternative study designs are not possible (eg, randomized control trials), such as when investigating the effect of geographical and temporal factors on disease incidence or the effect of a government policy change on health outcomes. In this overview, we provide an introduction to the use of ecological studies in cardiovascular outcomes research, drawing on published examples from our group and others. It is important for clinicians to be aware of both the potential strengths and weaknesses of this type of study design. Because ecological studies are ubiquitous in the medical literature, it is not possible to review all published cardiovascular ecological studies in a systematic manner. Individual-level variables are properties of each person whereas ecological variables are properties of groups, organizations, or places.1,2 All ecological studies are potentially prone to the so-called “ecological fallacy,” which is a term for the biases that may occur when the association that exists between variables at an aggregate level may not represent the true association that exists at an individual level.3 On the other hand, the ecological fallacy may be offset by avoidance of the “individualistic fallacy” whereby one assumes that individual patients are unaffected by the neighborhood in which they live or the setting in which they are treated.4 Complete …

Association between administered oxygen, arterial partial oxygen pressure and mortality in mechanically ventilated intensive care unit patients

IntroductionThe aim of this study was to investigate whether in-hospital mortality was associated with the administered fraction of oxygen in inspired air (FiO2) and achieved arterial partial pressure of oxygen (PaO2).MethodsThis was a retrospective, observational study on data from the first 24 h after admission from 36,307 consecutive patients admitted to 50 Dutch intensive care units (ICUs) and treated with mechanical ventilation. Oxygenation data from all admission days were analysed in a subset of 3,322 patients in 5 ICUs.ResultsMean PaO2 and FiO2 in the first 24 h after ICU admission were 13.2 kPa (standard deviation (SD) 6.5) and 50% (SD 20%) respectively. Mean PaO2 and FiO2 from all admission days were 12.4 kPa (SD 5.5) and 53% (SD 18). Focusing on oxygenation in the first 24 h of admission, in-hospital mortality was shown to be linearly related to FiO2 value and had a U-shaped relationship with PaO2 (both lower and higher PaO2 values were associated with a higher mortality), independent of each other and of Simplified Acute Physiology Score (SAPS) II, age, admission type, reduced Glasgow Coma Scale (GCS) score, and individual ICU. Focusing on the entire ICU stay, in-hospital mortality was independently associated with mean FiO2 during ICU stay and with the lower two quintiles of mean PaO2 value during ICU stay.ConclusionsActually achieved PaO2 values in ICU patients in The Netherlands are higher than generally recommended in the literature. High FiO2, and both low PaO2 and high PaO2 in the first 24 h after admission are independently associated with in-hospital mortality in ICU patients. Future research should study whether this association is causal or merely a reflection of differences in severity of illness insufficiently corrected for in the multivariate analysis.

Initiation and Use of Public Mental Health Services by Persons With Severe Mental Illness and Limited English Proficiency

Initiation and Use of Public Mental Health Services by Persons With Severe Mental Illness and Limited English Proficiency

Clinical Experience with Dexmedetomidine for Implantation of Deep Brain Stimulators in Parkinson's Disease

The pharmacologic profile of the alpha-2 agonist dexmedetomidine (Dex) suggests that it may be an ideal sedative drug for deep brain stimulator (DBS) implantation. We performed a retrospective chart review of anesthesia records of patients who underwent DBS implantation from 2001 to 2004. In 2003, a clinical protocol with Dex sedation for DBS implantation was initiated. Demographic data, use of antihypertensive medication, and duration of mapping were compared between patients who received Dex (11 patients/13 procedures) and patients who did not receive any sedation (controls: 8 patients/9 procedures). There were no differences in severity of illness between the two groups. Dex provided patient comfort and surgical satisfaction with mapping in all cases, and significantly reduced the use of antihypertensive medication (54% in the Dex group, versus 100% in controls, P = 0.048). In DBS implantation, sedation with Dex did not interfere with electrophysiologic mapping, and provided hemodynamic stability and patient comfort. Routine use of Dex in these procedures may be indicated.

Risk Factors and Outcomes Associated With Non–Enterococcus faecalis, Non–Enterococcus faeciumEnterococcal Bacteremia

To compare risk factors, clinical features, and outcomes in patients with Enterococcus avium, Enterococcus casseliflavus, Enterococcus durans, Enterococcus gallinarum, and Enterococcus mundtii bacteremia (cases) with those in patients with Enterococcus faecalis bacteremia (controls). A retrospective case-control study. A 725-bed, university-affiliated, academic medical center. The clinical microbiology database at Northwestern Memorial Hospital from January 1994 to May 2003 was searched to identify cases; each case was matched to one control on the basis of date of admission. Thirty-three cases were identified and matched with 33 controls. The mean duration of hospital stay was longer (29.7 vs 17.2 days; P = .03) and the mean time to acquisition of bacteremia was greater (16.5 vs 6.3 days; P = .003) for cases than controls. Cases were more likely to have underlying hematologic malignancies (P < .001), to have been treated with corticosteroids (P = .02), and to be neutropenic (P = .003). Controls were more likely to have an indwelling bladder catheter (P = .01), and cases were more likely to have the gastrointestinal tract as a source of infection (P = .007) and to have concurrent cholangitis (P = .002). There were no differences in severity of illness or in mortality rates. Compared with patients with E. faecalis bacteremia, patients with non-E. faecalis, non-Enterococcus faecium enterococcal bacteremia were more likely to have a hematologic malignancy, prior treatment with corticosteroids, neutropenia, and cholangitis; longer duration of hospital stay was also identified as a clinical feature. However, non-E. faecalis, non-E. faecium species are not associated with any differences in mortality.

Impaired Oxidative Metabolism Precipitates Delirium: A Study of 101 ICU Patients

Data from 101 consecutively admitted intensive care unit (ICU) patients were examined to determine whether oxidative metabolic stress existed within the 48 hours before delirium onset. The occurrence of pneumonia and sepsis at any time during hospitalization was also recorded. Delirium was defined retrospectively with the Confusion Assessment Method (CAM). Older patients were found to develop delirium more frequently than younger patients. There were no differences in illness severity (APACHE II) between those who developed delirium and those who did not. Three measures of oxygenation (hemoglobin, hematocrit, pulse oximetry) were worse in the patients who later developed delirium. Two measures of oxidative stress (sepsis, pneumonia) occurred more frequently among those diagnosed with delirium. Hence, patients with indicators of oxidative dysfunction developed delirium more frequently, and this was not linked to illness severity.

Variation in pediatric intensive care therapies and outcomes by race, gender, and insurance status*

The differential allocation of medical resources to adult patients according to characteristics such as race, gender, and insurance status raises the serious concern that such issues apply to critically ill children as well. This study examined whether medical resources and outcomes for children admitted to pediatric intensive care units differed according to race, gender, or insurance status. An observational analysis was conducted with use of prospectively collected data from a multicenter cohort. Data were collected on 5,749 consecutive admissions for children from three pediatric intensive care units located in large urban children's hospitals. Children aged </=18 years admitted over an 18-month period beginning in June 1996 formed the study sample. Hospital mortality, length of hospital stay, and overall resource use were examined in relation to severity of illness. Standardized ratios were formed with generalized regression analyses that included the Pediatric Index of Mortality for risk adjustment. After adjustment for differences in illness severity, standardized mortality ratios and overall resource use were similar with regard to race, gender, and insurance status, but uninsured children had significantly shorter lengths of stay in the pediatric intensive care unit. Uninsured children also had significantly greater physiologic derangement on admission (mortality probability, 8.1%; 95% confidence interval [CI], 6.2-10.0) than did publicly insured (3.6%; 95% CI, 3.2-4.0) and commercially insured patients (3.7%; 95% CI, 3.3-4.1). Consistent with greater physiologic derangement, hospital mortality was higher among uninsured children than insured children. Risk-adjusted mortality and resource use for critically ill children did not differ according to race, gender, or insurance status. Policies to expand health insurance to children appear more likely to affect physiologic derangement on admission rather than technical quality of care in the pediatric intensive care unit setting.

The Paradox of the Nested Pediatric Emergency Department

Nested pediatric emergency departments (nPEDs) are defined as dedicated treatment areas operating during peak pediatric hours within general emergency departments (EDs). This study examined three staffing models for nPEDs and their impact on pediatric encounters. Three models were applied to children younger than 37 months presenting to the ED of an urban community hospital over one year. In the nPED, physicians cared only for nPED patients. In the restricted (rPED) model, physicians cared only for pediatric patients presenting outside nPED hours. In the total ED (tED) model, physicians treated all pediatric patients regardless of time. Full-time equivalent pediatric encounters, potential neonatal lumbar punctures, and illness severity were determined for all models. Statistical analysis was performed by analysis of variance and chi-square test. For the 3,389 eligible ED visits, the number of annual patient encounters per full-time equivalent was 1,236 for the nPED, 805 for the tED, and 336 for the rPED (p < 0.001). Physicians practicing only in the nPED treated 3.7 times the number of children younger than 37 months than did physicians in the rPED model and 1.5 times the number than did physicians in the tED model. Spending 10% of total practice hours in the nPED would increase pediatric encounters 26% for rPED physicians, while practicing 25% of time in the nPED would increase pediatric encounters 67% and equate to 45% of nPED encounters. An nPED physician could expect to perform 17 neonatal lumbar punctures, compared with ten for a tED physician and four for an rPED physician (p < 0.001). There was no significant difference in severity of illness for the three models. Physicians practicing in facilities that include an nPED must dedicate some portion of their practice to the nPED to maintain equivalent pediatric encounters.