Pediatrics
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Randomized Controlled Trial Clinical Trial
Successful direct extubation of very low birth weight infants from low intermittent mandatory ventilation rate.
It is common practice to use endotracheal continuous positive airway pressure for various time periods up to 24 hours before attempting extubation in infants who are mechanically ventilated. A few studies in newborns have indicated that airway resistance is increased through small endotracheal tubes. This increases the work of breathing and the likelihood of subsequent ventilatory failure. ⋯ All 13 study infants were successfully extubated without significant apnea or respiratory acidosis. Of the 14 control infants, only seven were successfully extubated; six infants had significant apnea and in one infant respiratory acidosis with pH 7.13 and PCO2 65 developed while receiving continuous positive airway pressure (13/13 v 7/14, P less than .005). The seven infants who failed the preextubation trial of continuous positive airway pressure were later extubated from low intermittent mandatory ventilation rates without significant apnea or respiratory acidosis.(ABSTRACT TRUNCATED AT 250 WORDS)
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Many people believe that temperature response to antipyretics in febrile children varies according to diagnosis. To evaluate the validity of this premise, we prospectively studied the temperature response to acetaminophen of febrile children who came to an urban pediatric emergency and walk-in facility. The study group consisted of 1,559 patients between the ages of 8 weeks and 6 years whose temperatures when seen were greater than 38.4 degrees C and who had not received antipyretic treatment within the previous four hours. ⋯ Children with cultures positive for bacterial disease or chest x-ray films positive for pneumonia had slightly greater one- and two-hour temperature decreases compared with children with other diagnoses. Although statistically significant, we do not consider these differences in response to be clinically useful. We conclude that fever response to acetaminophen is not a clinically useful indicator by which to differentiate the causes of febrile illnesses in young children.
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Randomized Controlled Trial Comparative Study Clinical Trial
Physician reimbursement by salary or fee-for-service: effect on physician practice behavior in a randomized prospective study.
We used a resident continuity clinic to compare prospectively the impact of salary v fee-for-service reimbursement on physician practice behavior. This model allowed randomization of physicians into salary and fee-for-service groups and separation of the effects of reimbursement from patient behavior. Physicians reimbursed by fee-for-services scheduled more visits per patient than did salaried physicians (3.69 visits v 2.83 visits, P less than .01) and saw their patients more often (2.70 visits v 2.21 visits, P less than .05) during the 9-month study. ⋯ Evaluating visits by American Academy of Pediatrics' guidelines indicated that fee-for-service physicians saw more patients for well-childcare than salaried physicians because they missed fewer recommended visits and scheduled visits in excess of those recommendations. Fee-for-service physicians also provided better continuity of care than salaried physicians by attending a larger percentage of all visits made by their patients (86.6% of visits v 78.3% of visits, P less than .05), and by encouraging fewer emergency visits per enrolled patient (0.12 visits v 0.22 visits, P less than .01). Physicians' interest in private practice, as determined by their career plans, correlated significantly with total number of patients enrolled (r = .48, P less than .05) and total clinic patients seen by each resident during the study (r = .40, P less than .05).(ABSTRACT TRUNCATED AT 250 WORDS)
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Acute rheumatic fever is reported to have declined and perhaps be vanishing. Prompted by the occurrence of 17 cases of acute rheumatic fever in an 18-month period in 1985 and 1986, we reviewed the records of 243 children with acute rheumatic fever who were cared for at Children's Hospital of Pittsburgh or Mercy Hospital between 1965 and 1986. Acute rheumatic fever was diagnosed using the modified Jones criteria and cases were classified by major criteria as arthritis, arthritis and carditis, carditis alone, carditis and chorea, chorea alone, and arthritis and chorea. ⋯ When demographic features of the children were contrasted with those in the previous two decades, a decrease in the proportion of children who lived in urban areas and who were black was noted. Four children had a history of preceding sore throat but only three sought medical care; nine children had no memorable illness and four had either a nonrespiratory illness or a respiratory infection without sore throat. This resurgence of rheumatic fever serves as a reminder that a diligent approach to the diagnosis and therapy of streptococcal infections remains essential.