Pediatrics
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Comparative Study
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. ⋯ 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.
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The diagnosis of persistent pulmonary hypertension (PPHN) can often be difficult to make, especially in a clinical setting in which pediatric echocardiography is not readily available. A noninvasive test that could differentiate PPHN from other cardiorespiratory disease would be very useful in the early management of the disease, because it would allow rapid identification of those infants at greatest risk of requiring the services of a level 3 nursery. Brain-type natriuretic peptide (BNP) is an endogenous peptide hormone secreted by the cardiac ventricles in response to increased wall stress and related ventricular filling pressures. The purpose of this study was to determine if BNP levels are elevated in newborns with PPHN and therefore may be used as a marker for differentiating PPHN from other forms of respiratory disease during the early newborn period. ⋯ Our findings indicate that BNP levels are elevated in infants with PPHN but not in infants with other forms of respiratory distress not associated with PPHN. Elevated BNP levels in term or near-term infants with respiratory distress should increase the suspicion of PPHN. Serial determination may also be helpful in monitoring the clinical course of such infants.
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Nonpowder guns (ball-bearing [BB] guns, pellet guns, air rifles, paintball guns) continue to cause serious injuries to children and adolescents. The muzzle velocity of these guns can range from approximately 150 ft/second to 1200 ft/second (the muzzle velocities of traditional firearm pistols are 750 ft/second to 1450 ft/second). Both low- and high-velocity nonpowder guns are associated with serious injuries, and fatalities can result from high-velocity guns. ⋯ The introduction of high-powered air rifles in the 1970s has been associated with approximately 4 deaths per year. The advent of war games and the use of paintball guns have resulted in a number of reports of injuries, especially to the eye. Injuries associated with nonpowder guns should receive prompt medical management similar to the management of firearm-related injuries, and nonpowder guns should never be characterized as toys.
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Comparative Study
Policy versus practice: comparison of prescribing therapy and durable medical equipment in medical and educational settings.
The American Academy of Pediatrics (AAP) has promoted pediatrician involvement in the care of children with special health care needs (CSHCN), including the prescription and/or supervision of therapies and durable medical equipment (DME) for children in both medical and educational settings, such as schools and early intervention programs. Through this survey, we attempted to quantify objectively how pediatricians direct and coordinate therapy and DME for CSHCN and how these efforts correlate with AAP recommendations. ⋯ Ideally, there should be a seamless continuity and cooperation among the environments of medicine, home, community, and education rather than separate and perhaps conflicting domains. All health care professionals and other service providers involved should be acknowledged as collaborative team members. Except for provision of the diagnosis, the majority of surveyed pediatricians do not comply with AAP policy recommendations on prescribing community/medical-based and educationally based services for CSHCN. Furthermore, the majority are willing to defer these decisions to other NPHCP. This raises issues regarding overall continuity of care versus care of the child in a variety of environments, the concept of the medical home, and legal risk as a result of failure to follow federal and state practice guidelines. Also, there seem to be different cultural perceptions among physicians and educationally based service providers regarding the physician's role in educationally based services. These cultural differences should be explored further to promote a greater collegial cooperation and understanding. Decreasing involvement of private outpatient pediatricians in coordinating and supervising CSHCN care and a trend toward greater deference to NPHCP since 1979 were noted. If the numerous policies and guidelines previously promoted by AAP have not had a significant impact on pediatrician practices in these fields, then other, more effective alternatives should be explored.