Large Tertiary Pediatric Hospital Research Articles

Analysis of Pediatric Facial Dog Bites

The aim of this study was to characterize and report the epidemiological data regarding pediatric facial dog bites. For this study, a retrospective chart review was used. This study was performed at a large tertiary pediatric hospital. All children younger than 18 years who sought medical attention after a facial dog bite between January 1, 2003, and December 31, 2008, were included. Demographic and epidemiologic data were collected and analyzed. A total of 537 children were identified. The average age was 4.59 ± 3.36 years, with a slight male preponderance (52.0%). The majority of dog bites occurred in children 5 years of age or younger (68.0%). Almost all (89.8%) of the dogs were known to the children. When circumstances surrounding the bite were documented, over half (53.2%) of the cases were provoked. The most common breeds were mixed breed (23.0%), Labrador retriever (13.7%), Rottweiler (4.9%), and German shepherd (4.4%). Inpatient treatment was required in 121 (22.5%) patients with an average length of stay of 2.96 ± 2.77 days. Children 5 years or younger were more likely to be hospitalized than older children. Children 5 years old and younger are at high risk for being bitten in the face by a familiar dog and are more likely to require hospitalization than older children. Certain dog breeds are more likely to bite, and there is often a history of provocation. There is a tremendous financial and psychosocial burden associated with dog bites, and prevention strategies should focus on education with the aid of public policies and better documentation and reporting systems.

Pilotprojekt einer pädiatrischen Antibiotic-Stewardship-Initiative am Dr. von Haunerschen Kinderspital - neue Wege der pädiatrischen Infektiologie

The steady increase in antimicrobial resistance is of growing concern in healthcare. Antibiotic Stewardship [ABS] Strategies are important tools to control antibiotic use and -prevent antimicrobial resistance. An increasing number of institutions are developing ABS initiatives also in pediatrics. However, few data are available assessing the implementation and efficiency of these pediatric ABS programs.At the Dr. von Hauner Children's Hospital, Ludwig-Maximilian University, a tertiary care pediatric reference center, a pediatric ABS Team has been implemented. Key structural elements were the same as for adult patients, but antimicrobials agents selected for monitoring and appropriate clinical endpoints are different in pediatrics.Key features were: 1. prospective-audit with feedback and formulary restriction and 2. pre-authorization (also referred to as prior approval). The ABS team consisted of one pediatric infectious disease specialist, one clinical fellow in pediatric infectious diseases, and one clinical pharmacist with training in infectious diseases.With the implementation of a pediatric ABS strategy we could significantly influence antimicrobial consumption in our hospital. Cost-savings are estimated to be above 330 000 € per year, and concomitantly the use of broad-spectrum antibiotics and antifungal compounds was significantly reduced.Antibiotic Stewardship [ABS] Strategies may be an effective tool to control antibiotic use in the setting of a large tertiary pediatric teaching hospital. A national guideline for ABS initiatives may help to further improve rational use of antibiotics in the hospital setting.

Morbidly obese paediatric patients are not adequately screened for comorbidities.

Although childhood obesity is common, many paediatric practitioners are not familiar with screening for its associated, serious comorbidities. We aimed to determine the adequacy of screening for nine well-recognized comorbidities in outpatients with severe morbid obesity (body mass index [BMI] ≥50 kg m(-2) ) seen in a large tertiary paediatric hospital. Patients with a BMI of ≥50 kg m(-2) seen at Texas Children's Hospital during calendar year 2009 were identified. Their medical records were reviewed for any documentation where hypertension, cardiac dysfunction, sleep apnoea, hepatosteatosis, diabetes, pseudotumour cerebri, dyslipidemia, orthopaedic issues and depression were noted and/or addressed as evidence of clinician awareness of these problems. We identified 123 patients seen at least once in 2009, with an average of 3.4 physician visits per patient and by an average of 2 different specialists. Hypertension screening was the most documented (91% of patients) and depression screening was the least documented (41%) in this patient cohort. Twelve patients (10%) had documented screening for all nine comorbidities. Overall, 55 patients (45%) had five or fewer of the nine comorbidities noted and/or addressed in the medical record. Adequate screening for comorbidities occurs in approximately half of children with severe morbid obesity, which means that many of these comorbidities are not being identified or treated. Educational programmes and new methodologies are needed to ensure comprehensive care of children with morbid obesity.

Pediatric Toxic Epidermal Necrolysis

Stevens Johnson Syndrome (SJS) and toxic epidermal necrolysis (TEN) are rare debilitating mucocutaneuous diseases most commonly associated with severe drug reactions. A review of SJS/TEN cases was undertaken to describe the etiology, patient characteristics, treatment, and outcome in children affected at a large tertiary pediatric hospital. A retrospective chart review examined SJS/TEN cases admitted to a pediatric intensive care unit (PICU) between 2001 and 2011. Data concerning total body surface area (TBSA) involvement, causative agents, length of stay, and treatment were reviewed. PICU mortality predictors including Severity-of-Illness Score for Toxic Epidermal Necrolysis (SCORTEN), Pediatric Index of Mortality 2 scores, and Pediatric Logistic Organ Dysfunction scores were also reviewed. Nutritional feeding information was collected and compared with calculated and measured (calorimetry) requirements. There were 10 SJS/TEN pediatric patients (mean age = 6.6 years) with significant skin involvement (mean TBSA = 42.2%) requiring PICU admission. Prescription drugs were the most common causative factor (n = 7). Intravenous immunoglobulin and corticosteroids were used for treatment in eight and two of the cases, respectively. The mean length of stay in the PICU was 10.2 days. There were no mortalities, and all mortality scores predicted high likelihood of survival. Actual feeds (n = 9) were uniformly lower than the calculated feeding requirements (mean = 1059 kcal/day vs mean = 2027 kcal/day). This data will help to provide insight into the management of SJS/TEN in an intensive care setting, and will help form the best treatment approach for future cases in a pediatric population.

Nosocomial rotavirus gastroenterocolitis in a large tertiary paediatric hospital in Warsaw, 2006-2010.

IntroductionRotaviruses are the leading cause of community-acquired and nosocomial gastroenterocolitis in children. There are limited data concerning the epidemiology of nosocomial rotavirus gastroenterocolitis (NRVG) in Central European countries, including Poland. The aim of our study was to analyse the epidemiology of NRVG in a large tertiary hospital in Warsaw.Material and methodsWe analysed retrospectively data of 63 173 patients aged 0-18 years hospitalized in the period 2006-2010. Nosocomial rotavirus gastroenterocolitis was defined as acute gastroenterocolitis (> 3 loose, or looser than normal, stools in 24 h and/or vomiting), confirmed with rapid immunochromatographic test (BioMaxima, Poland), if symptoms developed > 48 h after admission.ResultsIn total 575 cases of NRVG were diagnosed. The cumulative attack rate of NRVG was calculated as 0.91% (95% CI: 0.85-0.98%). The incidence density was 2.05/1000 bed-days (95% CI: 0.19-0.22/1000 bed-days). The mean proportion of NRVG among all rotavirus infections was 24%. The highest rates of NRVG were noted at wards where the mean duration of hospital stay was longer than 5 days (General Paediatrics and Neonatal Pathology). Seventy-one percent of children with NRVG were younger than 2 years. The mean duration of hospital stay of children with NRVG was longer than the average duration of hospitalization (11.6 days vs. 4.6 days, p < 0.01).ConclusionsOur study showed a relevant incidence of NRVG, which can prolong the children's hospital stay. Limiting the number of NRVG is important to improve patients’ safety and to avoid additional costs. Routine vaccination against rotavirus diseases could reduce the number of NRVG.

Health-associated infections in a pediatric nephrology unit in China

Health care-associated infection (HAI) in children is associated with morbidity and mortality, prolonged hospital stay, and increased health care costs. We report the prevalence of HAIs in children admitted to the pediatric nephrology unit of a large tertiary care pediatric hospital in China between 2000 and 2008. A prospective infection control surveillance program led by physicians identified HAIs in admitted patients and sent monthly summary data to the hospital's Nosocomial Infections Committee. Infections at any body site meeting the Center for Disease Control and Prevention's former National Nosocomial Infection Surveillance System definitions were eligible for inclusion. Over the study period, various infection prevention and control strategies were introduced, including education on hand hygiene, measures to ensure appropriate antimicrobial prophylaxis for patients, and a guideline for antibiotic use. Of the 971 patients admitted, 81 had a total of 89 episodes of HAI (9.16%; 89/971); 75 patients (92.6%) had one HAI. The percentage of children acquiring HAI decreased from 12% to 6% over the observation period, representing a statistically significant linear trend. The most common type of HAI was respiratory tract infection (65.16%; n = 58), followed by gastrointestinal tract infection (11.24%; n = 10), skin and soft tissue infection (8.99% (n = 8), bloodstream infection (7.87%; n = 7), and urinary tract infection (6.74%; n = 6). The incidence of HAI in a pediatric nephrology ward decreased over an 8-year period, associated with a surveillance program and education directed at hand hygiene and appropriate antibiotic use. Despite a strict visitor policy, respiratory tract infection was the most common HAI seen.

Pediatric Dog Bite Injuries: A 5-Year Review of the Experience at The Children’s Hospital of Philadelphia

The objective of this study was to characterize the nature of dog bite injuries treated over a 5-year period at a large tertiary pediatric hospital and to identify relevant parameters for public education and injury prevention. Investigators performed a retrospective review of emergency room records of a single tertiary pediatric hospital. Records of all patients who were evaluated for dog bite injuries between April of 2001 and December of 2005 were reviewed. All demographic, patient, and injury details were recorded. Five hundred fifty-one patients aged 5 months to 18 years were treated in the emergency department after suffering dog bite injuries during the study period. The majority of injuries (62.8 percent) were sustained by male children. Dog bite injuries were most prevalent during the months of June and July (24.1 percent). Grade school-aged children (6 to 12 years) constituted the majority of victims (51 percent), followed by preschoolers (2 to 5 years; 24.0 percent), teenagers (13 to 18 years; 20.5 percent), and infants (birth to 1 year; 4.5 percent). Injuries sustained by infants and preschoolers often involved the face (53.5 percent), whereas older children sustained injuries to the extremities (60.7 percent). More than 30 different offending breeds were documented in the medical records. The most common breeds included pit bull terriers (50.9 percent), Rottweilers (8.9 percent), and mixed breeds of the two aforementioned breeds (6 percent). Pediatric dog bites are preventable injuries, yet they persist as a prevalent public health problem. Evaluation of data from high-volume tertiary pediatric health care institutions identifies predictable patterns of injury with respect to patient age and gender, animal breed, provocation, and seasonality.

Risk factors for perioperative adverse events in children with myotonic dystrophy

This study was conducted to identify patient-related, surgical, and anesthetic factors that would help predict adverse events and allow for better planning of perioperative care in children with myotonic dystrophy. This is a retrospective chart review from a large tertiary pediatric hospital. Data were collected on demographics, disease severity, surgical procedure, and anesthetic technique. Perioperative adverse events were recorded. Records on 27 patients having 78 anesthetics over a 17.5-year period were reviewed. The overall frequency of postoperative respiratory complications was 10%. Significant risk factors were high muscular impairment rating scale (MIRS) grade (P = 0.007), at least 2300 cytosine, thymine, guanine (CTG) repeats on the protein kinase gene of chromosome 19q (P = 0.009), a longer duration of surgery (RR = 14.0 for surgery lasting at least 1 h; P = 0.002), perioperative morphine use (RR = 7.7, 95% CI 2.2-12.8; P = 0.005), intubation (P = 0.02), and the use of muscle relaxant without reversal (RR = 15.5, P = 0.0002). Using a multivariate risk model, only MIRS grade and the use of muscle relaxant without reversal were shown to be significant independent risk factors (RR = 24.9, P < 0.0001). The MIRS is a statistically significant and clinically useful tool for predicting high perioperative risk. Patients with a high MIRS grade should therefore be considered for postoperative intensive care. The use of muscle relaxant without reversal was also shown to be a significant risk factor. Patients who require morphine infusions postoperatively might also be most safely managed in a high dependency unit.

Hypogammaglobulinemia in a pediatric tertiary care setting

Hypogammaglobulinemia has been described as a secondary consequence of many disorders. It is also the seminal finding in many primary immune deficiencies. There are few studies examining the global etiologies of hypogammaglobulinemia. This study undertook a database discovery of all cases of laboratory-defined hypogammaglobulinemia identified in a large tertiary care pediatric hospital setting between August of 1990 until June of 2006. Eight thousand three hundred and four IgG levels were sent during that time frame. One thousand two hundred and ninety-five specimens from 680 individual patients exhibited hypogammaglobulinemia and these patients represent the study population. The majority of cases in whom an identifiable cause was found had pre-existing conditions and the IgG level was sent as part of a monitoring process. Of the 366 patients who had an IgG level obtained for diagnostic purposes, nearly half were found to have an immune deficiency. One hundred and seventy-two patients with an immune deficiency were identified. Seven percent of these had severe combined immune deficiency. Seventy-four percent of the immune deficient patients identified required active intervention with IVIG, bone marrow transplantation or other management (not including prophylactic antibiotics). Evaluating all patients with IgG levels less than half of the lower limit for age revealed 122 patients of whom 33% had a primary immune deficiency. This study provides a framework for considering causes of hypogammaglobulinemia. At the study institution, hypogammaglobulinemia was found most often as a secondary immune deficiency due to chemotherapy or from complex cardiac anomalies. The magnitude of the secondary hypogammaglobulinemia in a tertiary care setting requires public health consideration as these patients have an unknown risk of infection and an unknown risk of prolonged viral shedding; issues which could be important in epidemic settings.

The Effect of Detection Approaches on the Reported Incidence of Tenfold Errors

Tenfold errors in calculation of paediatric drug doses are often life threatening. The magnitude and characteristics of this phenomenon have not been fully described. The objective of this study was to describe the incidence and nature of paediatric tenfold errors and to describe the effect of different detection approaches on the detection of such errors. To evaluate the incidence of tenfold errors, data were collected from three different studies on medication errors all conducted at a large tertiary care paediatric hospital: (i) a study investigating medication event reports to the hospital's Medication Incident Committee; (ii) a study auditing the charts of 1532 patients in the emergency department (ED) and; (iii) a prospective study of medication errors occurring during mock code resuscitations in the ED. In the first study, 20 tenfold errors were reported during the surveyed period. Almost all errors were prescribing errors. The calculated incidence was 1 per 22 500 doses prescribed. In chart auditing study in the ED, two tenfold errors where found in 1678 orders. In the prospective study, four tenfold errors were identified in eight mock resuscitations (125 orders for drugs). The incidence of tenfold errors in paediatrics varies dramatically when different detection approaches are used. The rate of tenfold errors may be especially high in resuscitation situations and is underestimated by spontaneous reporting.

The efficacy of morphine and Entonox analgesia during chest drain removal in children

Morphine is commonly used for chest drain removal pain, although a few studies in adults suggest that inhalation agents may be effective for this procedure. Little is known about chest drain removal pain and its management in children. Three separate studies were carried out at a large tertiary pediatric hospital to examine the characteristics and management of chest drain removal pain in children. Study 1 examined the prevalence and clinical characteristics of pain and analgesic practices in 135 nonventilated children aged 1 week to 18 years having chest drains removed. Study 2 was an observation study to determine the efficacy and safety of self-administered Entonox (50% nitrous oxide and oxygen) for chest drain removal pain in 30 children aged 7-18 years. Study 3 was a pilot randomized controlled trial comparing intravenous morphine and continuous flow Entonox for chest drain removal pain in 14 children aged 3.5 months to 2.75 years. In study 1, the prevalence of moderate to severe pain during chest drain removal was 76%. Morphine was commonly given preprocedure, but the dose varied considerably. In study 2, children experienced a significant increase in pain during the procedure compared with preprocedure pain at rest, despite receiving Entonox, morphine and/or diclofenac. However, procedure pain was no worse than preprocedure pain during movement or deep breathing. A few minor side effects occurred, which resolved spontaneously. In study 3, no differences were found in pain between the two treatment groups. Children experienced moderate to severe pain during the procedure, despite receiving Entonox or morphine. Morphine or Entonox alone are unlikely to provide adequate analgesia for chest drain removal pain in children. More research is needed to determine the most effective interventions for this procedure.

58 Parental Education and Cognitive Profiles at 4 Years of Age in Healthy Very Preterm Children.

BACKGROUND: Improved survival rates for preterm and very low birthweight infants have increased attention towards their long-time neuro-developmental outcome, and particularly cognitive performances. To discriminate the effects of preterm birth from those of its neurological and sensorial consequences, we studied the cognitive function of a sample of healthy preterm children (no IVH stage 3–4; PLV; ROP grade 3–4) at pre-school age.METHODS: Thirty-five healthy preterm children (gestational age less than 33 weeks) were assessed at mean age of 4.4 years (SD 0.3) together with 50 controls born at term and matched for age and gender. Cases were selected from patients attending follow up at a large tertiary Pediatric Hospital. Griffiths scales were used to measure cognitive development. Multivariate regression analysis was adopted to simultaneously explore the effects of preterm birth and socio-demographic factors on cognitive score: parent age and education.RESULTS: Ninty-six % of global developmental Griffiths scores of both cases and controls were within 83–116, corresponding to the scale range of low to high average. However, global mean scores were lower for cases (97) than controls (103) and the difference was statistically significant (p<0.05). In particular, scores of preterm infants were significantly lower in four subscales: locomotor, hand and eye co-ordination, performance, practical reasoning. After adjusting for socio-demographic variables in multivariate analysis, the difference in global scores remained statistically significant (p<0.01). Maternal education was also significant predictor of cognitive development (p<0.05) with higher educational level corresponding to better children performances.CONCLUSIONS: These findings suggest that healthy preterm children at pre-school age, despite a global developmental score in the normal range, still show a lower developmental profile than their term peers, and maternal education also exerts a significant effect. Lower subscale scores point to specific areas of difficulty. These findings have implication for subsequent school performance and therapeutic interventions.

Are Clinical Impressions of Adolescent Substance Use Accurate?

To compare providers' impressions of adolescents' level of substance use with diagnostic classifications from a structured diagnostic interview. Secondary analysis of data was conducted from a validation study of the CRAFFT substance abuse screening test of 14- to 18-year-old medical clinic patients (n = 533) and their corresponding medical care providers (n = 109) at an adolescent clinic affiliated with a large tertiary care pediatric hospital. Medical care providers completed a form that recorded their clinical impressions of patients' level of alcohol and drug involvement (none, minimal, problem, abuse, dependence) and demographic characteristics. The form included brief diagnostic descriptions for each level of use. After the medical visit, patients completed the Adolescent Diagnostic Interview (ADI), a structured diagnostic interview that yields diagnoses of abuse and dependence according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV). On the basis of their past 12 months of alcohol and drug use on the ADI interview, adolescents were classified into 5 mutually exclusive diagnostic groups. "None" was defined by no reported use of alcohol or drugs during the past year. "Minimal use" was defined as use of alcohol or drugs but no report of any substance-related problems. "Problem use" was defined as reporting 1 or more substance-related problems but no diagnosis of abuse or dependence. "Abuse" was defined by meeting any 1 of 4 DSM-IV diagnostic criteria for either alcohol or drug abuse but no diagnosis of dependence. "Dependence" was defined by meeting any 3 of 7 diagnostic criteria for either alcohol or drug dependence, with or without a diagnosis of abuse. Proportions were compared using Fisher exact test. Agreement was assessed with the weighted kappa, and these analyses were stratified by substance used (ie, alcohol vs drug) and demographic characteristics. Sensitivity, specificity, and positive and negative predictive values were calculated from 2 x 2 tables. Compared with the criterion standard interview, providers identified significantly fewer patients with problem use and abuse and no patients with dependence. Of >100 patients whom the ADI classified with substance problem use, providers correctly identified 18. Of 50 patients who were classified with a diagnosis of alcohol or drug abuse, providers correctly identified 10. Of 36 patients who were classified with a diagnosis of alcohol or drug dependence, providers correctly identified none. For the 86 adolescents who were classified with a substance-related disorder (ie, abuse or dependence), providers' impressions were "none" (24.4%), "minimal use" (50%), "problem use" (15.1%), "abuse" (10.5%), and "dependence" (0%). There was only marginal agreement between providers' impressions and diagnoses related to alcohol use (kappa = .29), drug use (kappa = .31), and any substance use (kappa = .30). Kappa was not significantly affected by the patient's age, but it was by gender. Among boys, kappa was significantly higher for impressions of drug use versus alcohol use (kappa = .48 vs kappa = .27); and, among drug users, kappa was significantly higher among boys compared with girls (kappa = .48 vs kappa = .24). Kappa did not differ significantly across race/ethnicity subgroups, although there is a suggestive trend toward higher agreement for black non-Hispanic compared with white non-Hispanic adolescents (kappa = .35 vs kappa = .21). Kappa did not differ significantly on the basis of the visit type, but the size of this difference (kappa = .36 vs kappa = .24) suggests that the longer well-child visit yielded greater identification of substance-related pathology. Providers' impressions had a sensitivity of .63 for identifying use of alcohol or drugs. However, sensitivity was poor for identification of problem use (.14), abuse (.10), and dependence (0), whereas specificity and positive predictive values were high. Of the 86 adolescents with a diagnosis of abuse or dependence, 75.6% were correctly identified by providers as using substances; however, the level of use in 50% of these adolescents was reported by providers as minimal. In this study, clinical impressions of adolescents' alcohol/drug involvement underestimated substance-related pathology. When providers thought that use was present, there was a very high likelihood that a problem or disorder existed. The use of structured screening devices would likely improve identification of adolescents with substance-related pathology in primary care settings and should be considered for use with all adolescent patients, rather than only those who are perceived to be at higher risk.

Kawasaki disease at British Columbia's Children's Hospital

To describe the clinical features, diagnosis, treatment and outcome of children with Kawasaki disease (KD) treated at a large tertiary care Canadian paediatric hospital and to try to identify correlations between clinical features and the development of coronary artery abnormalities. The charts of 176 patients diagnosed with typical, atypical or incomplete KD between 1992 and 2000 at British Columbia's Children's Hospital were reviewed. The male to female ratio was 1.8:1. The median age was 2.5 years (range two months to 14 years), with 8% nine years or older (42% Caucasian, 43% Asian). Cases occurred steadily throughout the year. One hundred two (58%) patients had typical, 18 (10%) patients had atypical and 56 (32%) patients had incomplete KD. The median time from fever onset to first intravenous immunoglobulin (IVIG) was seven days (range two to 49 days), and treatment began within 10 days of fever onset in 134 (76%) patients. All patients received one or more doses of 2 g/kg IVIG. Forty-two (24%) patients received a second dose for nonresponsiveness, of whom 10 (6%) remained nonresponsive. Eight (5%) patients received intravenous methylprednisolone. Forty-eight (27%) patients developed coronary artery abnormalities, with 10 (6%) echogenic abnormalities, 25 (14%) dilatations and 13 (7%) aneurysms (seven giant). No patient with a normal echocardiogram at four to eight weeks developed an abnormality on subsequent study. Fourteen (8%) patients had persistent abnormalities at last follow-up (median 447 days, range 62 to 3272 days): seven dilations and seven aneurysms (six giant). Five of 13 children (39%) who developed aneurysms failed to meet diagnostic criteria for typical KD, and three of those five aneurysms were present at less than one year after diagnosis. Four of eight (50%) patients receiving intravenous methyl-prednisolone for IVIG nonresponsiveness had or developed aneurysms. One patient died. Some children diagnosed with KD who fail to meet the diagnostic description develop coronary artery abnormalities. There is a need for a more accurate means of diagnosis to more appropriately use IVIG, an expensive and increasingly scarce resource. The role of corticosteroids remains unclear and a randomized controlled clinical trial to determine their role is needed.

Diversity of enteric viruses detected in patients with gastroenteritis in a tertiary referral paediatric hospital.

The genetic diversity of enteric viruses co-circulating in a cohort of patients with viral gastroenteritis in a large tertiary paediatric hospital in London, UK, was determined. Multiple strains of noroviruses (NV), sapoviruses (SV) and astroviruses (HAsV) were detected in these patients, indicating the likelihood of multiple introductions from different sources, possible sub-clinical infections and simultaneous infection with different viruses in immunocompromised and other patients. Routine screening of immunocompromised patients and infection control procedures are important to prevent nosocomial infection.

Trends of medication errors in hospitalized children.

Medication errors are a major cause of morbidity and mortality among hospitalized children. Due to the small volumes of stock solution involved, even a large error may look as an unsuspiciously small dose. Strategies were implemented to reduce medication errors in a large tertiary pediatric hospital in Toronto. Starting in 1993, several initiatives were taken, including a new hospital computer system for medication ordering, a review process to remove hazardous drugs from wards where they are not needed immediately, and in the training of pediatric residents. The rates of reported medication errors were compared before and after these initiatives were taken. Compared to baseline, there was a steady and a statistically significant decrease in medication errors through the decade. Total errors (actual and potential) decreased for nurses and physicians by half and for pharmacists by 75%. Actual incidents decreased by half. Moderate and severe errors decreased by more than 70%. It was concluded that a combination of several initiatives to decrease system and human errors has resulted in more than a 50% reduction of medication errors reaching the pediatric patient.

Measuring quality of life in children with attention-deficit/hyperactivity disorder and their families: development and evaluation of a new tool.

To psychometrically evaluate a new parent-completed questionnaire that measures the effect of attention-deficit/hyperactivity disorder (ADHD) on the everyday well-being of children and their families. Using a mail-out/mail-back method, the sample was drawn from the registry of an outpatient developmental and behavioral program of a large tertiary pediatric hospital. All children received medication for ADHD. Responses were received for 81 children of whom 60 (74%) were boys. An even split of questionnaires was returned for children with ADHD primarily inattentive (50%) and ADHD combined (50%). The condition of 70 patients (86%) had been diagnosed for 1 year or longer; 69 patients (89%) reported receiving medication. The ADHD Impact Module, HealthAct, Boston, Mass, developed with input from families, measures the effect of the disorder on the child's emotional-social well-being (Child Scale, 8 items) and the family (Home Scale, 10 items). The scales exceeded standard criteria for item convergent and discriminant validity. No floor effects and minimal (2%) ceiling effects were observed. Cronbach alpha was 0.88 and 0.93 (Child and Home Scales), respectively. Raw scale scores are transformed on a 0 through 100 continuum; a higher score indicates more favorable findings. Statistically significant differences (P<.000) were observed for ADHD inattentive vs ADHD combined on both scales (Child, 65.26 vs 48.86; Home, 72.79 vs 51.26). Better "success at home" scores were reported by parents of ADHD inattentive children (Child Scale, 62.12 vs 47.36, P =.00; Home Scale, 70.58 vs 47.01, P =.000). The ADHD Impact Module meets stringent psychometric standards. Further validation is required, but current evidence suggests it is a promising new questionnaire.

Pilomatrixoma of the head and neck in children

Objective: Pilomatrixomas are benign skin neoplasms of hair follicle origin. They are one of the most common superficial masses of the head and neck excised in children. Although the entity has been well studied in the literature, few studies have been undertaken to evaluate the clinical characteristics of head and neck pilomatrixomas specifically in children. The purpose of this study was to review the clinical characteristics and management of children presenting with pilomatrixomas of the head and neck at a large tertiary care pediatric hospital. Study Design: A retrospective chart review was performed of all patients with histologically confirmed pilomatrixoma of the head and neck excised during a 6-year period (1992-1997) at the Children's Hospital of Philadelphia. Results: Ninety-one cases of pilomatrixoma were confirmed in 86 patients. The age range was 5 months to 17 years. The median age at time of excision was 6.0 years. The most common sites of occurrence were the cheek (36%), neck (20%), periorbital region (14%), and scalp (9%). The male to female ratio was 1:1.5. Multiple lesions were found in 8.2% of patients. Surgical excision was curative in all cases. Conclusion: Pilomatrixoma is a cutaneous neoplasm that is one of most common causes of superficial head and neck masses in children. Although the presurgical diagnosis may be difficult in some cases, pilomatrixoma must be kept in the differential of superficial head and neck masses in children. Surgical excision is almost always curative. (Otolaryngol Head Neck Surg 2001;125:510-5.)

Pulse oximetry in sickle cell anemia.

To determine whether pulse oximetry is accurate and if it correlates with arterial blood gas saturation in pediatric patients with sickle cell anemia. Prospective, comparative study using a convenience sample of patients with sickle cell anemia who had simultaneous arterial blood gas sampling and pulse oximetry. Children's Memorial Hospital, a large tertiary care pediatric hospital in Chicago, IL. Patients selected from the emergency department and the pediatric intensive care unit. Twenty-four consecutive patients with sickle cell anemia who had simultaneous arterial blood gas sampling and pulse oximetry. Twenty-four patients had a total of 70 simultaneous pulse oximeter and blood gas pair samples. Each patient's initial pulse oximeter/blood gas pair was used in the statistical analysis. Three patients had venous samples and were excluded from comparison, leaving 21 arterial blood gas/pulse oximeter pairs for analysis. The pulse oximeter correlated well with the cooximeter-measured arterial saturation (r(2) =.74). The pulse oximeter significantly underestimated saturation by a mean of -1.6% (95% confidence interval, -0.3 to -3; p =.03). Pulse oximetry correlates well with cooximeter-measured saturation in patients with sickle cell anemia. Pulse oximetry significantly underestimates true arterial saturation, but the bias is clinically insignificant. Pulse oximetry can be used reliably to estimate the arterial oxygen saturation in patients with sickle cell anemia.

Homonymous hemifield loss in childhood

The differential diagnosis of etiologies of homonymous hemianopias and quadrantanopias in children is not discussed in standard pediatric neurology1,2 or neuro-ophthalmic3 textbooks. We reviewed our experience with pediatric patients with homonymous hemifield loss to elucidate the responsible causes and their relative frequency. Methods. Since July 1993 all inpatients and outpatients with neuro-ophthalmic diagnoses seen and examined by one of us (G.T.L.) in a pediatric neuro-ophthalmic practice at the Children's Hospital of Philadelphia have been entered into a database. Patient referrals were made primarily from neurosurgery, neurooncology, neurology, ophthalmology, and rehabilitation services at this large tertiary care pediatric hospital. Criteria for patient inclusion in this present study were as follows: (1) age 18 years or younger at the onset of visual loss; (2) acquired homonymous hemianopia or quadrantanopia lasting at least 24 hours; (3) verification of the responsible process and its localization by neuroimaging; and (4) the patient was seen between July 1993 and February 1997. Patients with cortical visual impairment caused by bilateral lesions were excluded. Visual field assessment. Visual fields were documented with kinetic perimetry, computerized threshold perimetry, or confrontation. The method used depended on the cooperation of …