Pediatrics
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Comparative Study
Can regionalization decrease the number of deaths for children who undergo cardiac surgery? A theoretical analysis.
The association between high case volumes and better patient outcomes has been demonstrated for many surgical procedures and medical treatments, including surgery for children with congenital heart disease. To simulate the effects of regionalization of pediatric cardiac surgery, we assessed the impact of reducing the number of pediatric cardiac centers on surgical mortality and patient's travel distance. ⋯ Theoretical regionalization of pediatric cardiac surgery is associated with a reduction in surgical mortality from 5.34% to 4.08% when all cases were referred to high-volume hospitals, or decrease to 4.60% when high-risk cases were referred. Although regionalization is associated with an important decrease in the number of deaths, it also increases the travel distance for patients. Additional studies on the costs and benefits of regionalization are needed to determine the best strategies to improve outcomes for children who undergo cardiac surgery.
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In an era when expanding publicly funded health insurance to children in higher income families has been the major strategy to increase access to health care for children, it is important to determine if the benefits to higher income children attributable to the receipt of health coverage are similar to those observed for lower income children. This study investigated how the likely impact of child health insurance expansions varies with family income. ⋯ Our findings demonstrate the positive impact of providing health insurance coverage to children regardless of income. The HI children who enrolled in the program looked similar to children with incomes that meet current SCHIP eligibility guidelines, suggesting that expansions of SCHIPs to HI children should not qualitatively change the program dynamics.
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Data regarding pediatric in-hospital cardiopulmonary resuscitation (CPR) have been limited because of retrospective study designs, small sample sizes, and inconsistent definitions of cardiac arrest and CPR. The purpose of this study was to prospectively describe and evaluate pediatric in-hospital CPR with the international consensus-derived epidemiologic definitions from the Utstein guidelines. ⋯ During this study, CPR was uncommon but not rare. Respiratory failure was the most common precipitating cause, followed by shock. Preexisting chronic diseases were prevalent among these children. Asystole was the most common initial cardiac rhythm, and bradycardia with pulses and poor perfusion was the second most common. Ventricular fibrillation was rare, but children with acute cardiac diseases, such as cardiac surgery and acute cardiomyopathies, were not admitted to this children's hospital. CPR was effective: nearly two thirds of these children were initially successfully resuscitated, and one third were alive at 24 hours compared with imminent death without CPR and advanced life support. Nevertheless, survival progressively decreased over time, generally as a result of the underlying disease process. One-year survival was 15%. Importantly, most of these survivors had no demonstrable change in gross neurologic function from their pre-CPR status.
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Guidelines for risk reduction during procedural sedation from the American Academy of Pediatrics (AAP) and the American Society of Anesthesiologists (ASA) rely on expert opinion and consensus. In this article, we tested the hypothesis that application of an AAP/ASA-structured model would reduce the risk of sedation-related adverse events. ⋯ Presedation assessment reduces complications of DS. Repeated assessment of sedation score reduces the risk of inadvertent DS. The data provide direct evidence that AAP/ASA guidelines can reduce the risk of pediatric procedural sedation.
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Activated CD8 as well as CD4 T cells contribute to the production of asthma-relevant cytokines in both atopic and nonatopic childhood asthma. ⋯ The data are consistent with the hypothesis that both activated CD4 and CD8 T cells are associated with child asthma, and that CD4 T cells make a greater contribution to IL-4 and IL-5 synthesis. Increased dosages of inhaled glucocorticoid resulted in clinical improvement in the asthmatics along with reduced T-cell activation and cytokine mRNA expression, suggesting a possible causal association.