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Background: Based on regional and anecdotal reports, there is concern that vitamin D-deficiency rickets is persistent in Canada despite guidelines for its prevention. We sought to determine the incidence and clinical characteristics of vitamin D-deficiency rickets among children living in Canada., Methods: A total of 2325 Canadian pediatricians were surveyed monthly from July 1, 2002, to June 30, 2004, through the Canadian Paediatric Surveillance Program to determine the incidence, geographic distribution and clinical profiles of confirmed cases of vitamin D-deficiency rickets. We calculated incidence rates based on the number of confirmed cases over the product of the length of the study period (2 years) and the estimates of the population by age group., Results: There were 104 confirmed cases of vitamin D- deficiency rickets during the study period. The overall annual incidence rate was 2.9 cases per 100,000. The incidence rates were highest among children residing in the the north (Yukon Territory, Northwest Territories and Nunavut). The mean age at diagnosis was 1.4 years (standard deviation [SD] 0.9, min-max 2 weeks-6.3 years). Sixty-eight children (65%) had lived in urban areas most of their lives, and 57 (55%) of the cases were identified in Ontario. Ninety-two (89%) of the children had intermediate or darker skin. Ninety-eight (94%) had been breast-fed, and 3 children (2.9%) had been fed standard infant formula. None of the breast-fed infants had received vitamin D supplementation according to current guidelines (400 IU/d). Maternal risk factors included limited sun exposure and a lack of vitamin D from diet or supplements during pregnancy and lactation. The majority of children showed clinically important morbidity at diagnosis, including hypocalcemic seizures (20 cases, 19%)., Interpretation: Vitamin D-deficiency rickets is persistent in Canada, particularly among children who reside in the north and among infants with darker skin who are breast-fed without appropriate vitamin D supplementation. Since there were no reported cases of breast-fed children having received regular vitamin D (400 IU/d) from birth who developed rickets, the current guidelines for rickets prevention can be effective but are not being consistently implemented. The exception appears to be infants, including those fed standard infant formula, born to mothers with a profound vitamin D deficiency, in which case the current guidelines may not be adequate to rescue infants from the vitamin D-deficient state.

Objective: Our goal was to determine which of 3 analgesics, acetaminophen, ibuprofen, or codeine, given as a single dose, provides the most efficacious analgesia for children presenting to the emergency department with pain from acute musculoskeletal injuries., Patients and Methods: Children 6 to 17 years old with pain from a musculoskeletal injury (to extremities, neck, and back) that occurred in the preceding 48 hours before presentation in the emergency department were randomly assigned to receive orally 15 mg/kg acetaminophen, 10 mg/kg ibuprofen, or 1 mg/kg codeine. Children, parents, and the research assistants were blinded to group assignment. The primary outcome was change in pain from baseline to 60 minutes after treatment with study medication as measured by using a visual analog scale., Results: A total of 336 patients were randomly assigned, and 300 were included in the analysis of the primary outcome (100 in the acetaminophen group, 100 in the ibuprofen group, and 100 in the codeine group). Study groups were similar in age, gender, final diagnosis, previous analgesic given, and baseline pain score. Patients in the ibuprofen group had a significantly greater improvement in pain score (mean decrease: 24 mm) than those in the codeine (mean decrease: 11 mm) and acetaminophen (mean decrease: 12 mm) groups at 60 minutes. In addition, at 60 minutes more patients in the ibuprofen group achieved adequate analgesia (as defined by a visual analog scale <30 mm) than the other 2 groups. There was no significant difference between patients in the codeine and acetaminophen groups in the change in pain score at any time period or in the number of patients achieving adequate analgesia., Conclusions: For the treatment of acute traumatic musculoskeletal injuries, ibuprofen provides the best analgesia among the 3 study medications.

Background: Procedural pain relief is sub-optimal in neonates. Topical tetracaine provides pain relief in children. Evidence of its efficacy and safety in neonates is limited. The objective of this study was to assess the efficacy and safety of topical tetracaine on the pain response of neonates during a venipuncture., Methods: Medically stable infants greater than or equal to 24 weeks gestation, requiring a venipuncture, were included. Following randomization and double blinding, 1.1 g of tetracaine or placebo was applied to the skin for 30 minutes. Participants received oral sucrose if they met local eligibility criteria. The venipuncture was performed according to a standard protocol. A medium effect size in the pain score (corresponding to about 2 point difference in the PIPP score) was considered clinically significant, leading to a sample size of 142 infants, with 80% statistical power. Local skin reactions and immediate adverse cardiorespiratory events were noted. The primary outcome, PIPP score at 1 minute, was analysed using an independent Student's t-test., Results: One hundred and forty two infants were included, 33 +/- 4 weeks gestation, 2100 +/- 900 grams and 6 +/- 3 days of age. There was almost no difference in PIPP scores at 1 minute between groups (mean difference -0.09; 95% confidence interval [CI]: -1.68 to 1.50; P = . 91). Similarly, there were no differences in PIPP scores during the 2nd, 3rd and 4th minute. Duration of cry did not differ between the groups (median difference, 0; 95% CI, -3 to 0; P = . 84). The majority of infants in both groups received sucrose 24%. Sucrose had a significant effect on the PIPP score, as assessed by an ANOVA model (p = 0.0026). Local skin erythema was observed transiently in 11 infants (7 in the tetracaine and 4 in the placebo group). No serious side effect was observed., Conclusion: Tetracaine did not significantly decrease procedural pain in infants undergoing a venipuncture, when used in combination with routine sucrose administration.

Hypoxia worsens brain injury following trauma, but the mechanisms remain unclear. The purpose of this study was to determine the effect of traumatic brain injury (TBI) and secondary hypoxia (9% oxygen) on apoptosis-related protein expression, cell death, and behavior. Using a murine weight-drop model, TBI led to an early (6 h) increase followed by a later (24 h) decrease in neuronal apoptosis inhibitor protein (NAIP) expression in the olfactory and motor cortex; in contrast, TBI led to a sustained (6 h to 7 days) increase in NAIP in the striatum. The peak increase in the expression of NAIP (6-12 h) following TBI alone was delayed (1-7 days) when hypoxia was added to TBI. Hypoxia following TBI further depleted other apoptosis inhibitor proteins (IAPs) and activated caspases, as well as increased contusion size and worsened cell death. Hypoxia added to TBI also increased motor and feeding activity on days 2 and 4 compared to TBI alone. Hypoxia without TBI had no effect on the expression of IAPs or cell death. These findings show that IAPs have a potential role in the increased vulnerability of brain cells to hypoxia following TBI, and have implications for configuring future therapies for TBI.

Background: We studied the effects of access to point-of-care medical evidence in a computerised physician order entry system (CPOE) on management and clinical outcome of children with bronchiolitis., Methods: This was a before-after study that took place in a Canadian tertiary care paediatric teaching hospital. The intervention was a clinical evidence module (CEM) for bronchiolitis management, adapted from Clinical Evidence (BMJ Publishing Group) and integrated into the hospital CPOE. CPOE users were medical trainees under the supervision of staff physicians working in the infant ward. Use of antibiotics, bronchodilators and corticosteroids; disease severity; length of hospital admission; and trainee use and perception of the CEM were measured before and after CEM introduction., Results: 334 paediatric inpatients age 2 weeks to 2 years, with a clinical diagnosis of bronchiolitis; 147 children the year preceding and 187 children the year following introduction of a Clinical Evidence Module (CEM). The percentage of patients receiving antibiotics fell from 35% to 22% (relative decrease 37%) following the introduction of the CEM (p = 0.016). Bronchodilator use was high but following the CEM patients no longer received more than one variety. Steroid usage and length of hospitalisation were low and unaffected. Trainees found the CEM to be educational., Conclusion: Readily accessible clinical evidence at the point of care was associated with a significant decrease in antibiotic use and an end to multiple bronchodilator use. The majority of physician trainees found the CEM to be a useful educational tool.

Background: St reptococcus pyogenes is an uncommon cause of community-acquired pneumonia in children. Further, its clinical course in comparison to pneumonia caused by Streptococcus pneumonia has not been previously highlighted., Methods: We reviewed medical records of children 0-18 years of age from April 1983 to April 2005, with discharge diagnoses of invasive disease caused by group A streptococcus (GAS) (Streptococcus pyogenes), or Streptococcus pneumonia (SP) or pneumonia. Data were extracted from the charts, and a comparison of clinical characteristics between the 2 etiologies was performed. Confirmed disease required blood or pleural fluid isolates. Patients with single isolates of GAS in tracheobronchial secretions or sputum were classified as having presumed disease caused by GAS. Patients with confirmed disease due to GAS and SP were compared with respect to clinical characteristics., Results: Of 103 patients with invasive GAS disease, 12 (11.6%) had confirmed GAS lobar pneumonia. In addition 7 patients had presumed GAS pneumonia. There were 54 patients with confirmed SP pneumonia. Most children who had GAS pneumonia were healthy and recovered completely. Compared with patients with confirmed SP pneumonia, those with confirmed GAS pneumonia had more frequent and larger effusions, more culture positive effusions, had prolonged fever, and had longer hospitalizations. There was not an increasing trend to GAS pneumonia over the 22-year period. There was not a predominant serotype responsible for the pneumonias., Conclusions: Lobar GAS pneumonia represents approximately 11% of all cases of invasive disease in this institution during a 22-year period. Compared with patients with SP pneumonia, it appears to cause more effusions and morbidity. The organism is also more frequently recovered from pleural fluid.

Aim: This paper reports the results of a survey of disadvantaged women in La Pintana, a municipality of Santiago, Chile, to determine their health decision-making needs., Background: Research is needed as there is no published community-based study focusing specifically on health decision-making needs of disadvantaged women., Methods: From April to November 1999, we conducted a cross-sectional interview survey of women registered at primary healthcare centres in La Pintana, an impoverished municipality of Santiago, Chile., Results: The survey participants were 554 adult women over 15 years of age. Seventy-five percent reported making current health-related decisions. Types of decisions were primarily about navigation: where, when and from whom to seek care. The most common role in decision-making was sharing the decision with others, specifically husbands and other family members. Fifty-four percent experienced decisional conflict or uncertainty about options. Those reporting more manifestations of decisional conflict were more likely to lack information on available options, pros and cons of the options, and chances of benefits and harms associated with the options; they were also more likely to be unclear about what was important to them, to feel pressure from others, lack skill or ability in decision-making and be older. The most common strategies used when making all types of decisions were obtaining information on options and recommendations, and getting support from others. Participants preferred to receive information about options through counselling from their physicians, rather than nurses, from printed materials and from discussion groups of people facing the same decision., Conclusion: The majority of disadvantaged women were actively involved in decision-making and needed decision support to navigate the healthcare system. Nurses should play a more pivotal role in providing health decision support. This study needs to be replicated in other countries and cultural contexts.

Haemophilus influenzae is a cause of otitis media with effusion (OME). Animal models demonstrate growth of H. influenzae biofilms in OME, which may explain why OME does not respond well to conventional antibiotic therapy. Using a previously developed in vitro model, we performed H. influenzae susceptibility studies to see if H. influenzae biofilm cultures were more resistant to antibiotics than planktonic (broth) cultures, and to determine which antibiotics were most effective against H. influenzae biofilms. H. influenzae isolates were grown as biofilms on polystyrene pins. Biofilm and planktonic minimum inhibitory concentrations (MICs) were measured for 8 antibiotics, and multiple combination testing was performed with 66 groupings of 1, 2, or 3 antibiotics. We found that biofilm cultures were more resistant to antibiotics than planktonic ones. Antibiotic combinations containing rifampin and ciprofloxacin were most effective against biofilms. Biofilm testing reveals differences in effectiveness among antibiotics not apparent from conventional susceptibility testing, and suggests novel antibiotic regimens that could be studied for treatment of OME.

Background: Individual trials to test effectiveness of antibiotics in children with acute otitis media have been too small for valid subgroup analyses. We aimed to identify subgroups of children who would and would not benefit more than others from treatment with antibiotics., Methods: We did a meta-analysis of data from six randomised trials of the effects of antibiotics in children with acute otitis media. Individual patient data from 1643 children aged from 6 months to 12 years were validated and re-analysed. We defined the primary outcome as an extended course of acute otitis media, consisting of pain, fever, or both at 3-7 days., Findings: Significant effect modifications were noted for otorrhoea, and for age and bilateral acute otitis media. In children younger than 2 years of age with bilateral acute otitis media, 55% of controls and 30% on antibiotics still had pain, fever, or both at 3-7 days, with a rate difference between these groups of -25% (95% CI -36% to -14%), resulting in a number-needed-to-treat (NNT) of four children. We identified no significant differences for age alone. In children with otorrhoea the rate difference and NNT, respectively, were -36% (-53% to -19%) and three, whereas in children without otorrhoea the equivalent values were -14% (-23% to -5%) and eight., Interpretation: Antibiotics seem to be most beneficial in children younger than 2 years of age with bilateral acute otitis media, and in children with both acute otitis media and otorrhoea. For most other children with mild disease an observational policy seems justified.

Objective: To determine whether the adoption of the CONSORT checklist is associated with improvement in the quality of reporting of randomised controlled trials (RCTs)., Data Sources: MEDLINE, EMBASE, Cochrane CENTRAL, and reference lists of included studies and of experts were searched to identify eligible studies published between 1996 and 2005., Study Selection: Studies were eligible if they (a) compared CONSORT-adopting and non-adopting journals after the publication of CONSORT, (b) compared CONSORT adopters before and after publication of CONSORT, or (c) a combination of (a) and (b). Outcomes examined included reports for any of the 22 items on the CONSORT checklist or overall trial quality., Data Synthesis: 1128 studies were retrieved, of which 248 were considered possibly relevant. Eight studies were included in the review. CONSORT adopters had significantly better reporting of the method of sequence generation (risk ratio [RR], 1.67; 95% CI, 1.19-2.33), allocation concealment (RR, 1.66; 95% CI, 1.37-2.00) and overall number of CONSORT items than non-adopters (standardised mean difference, 0.83; 95% CI, 0.46-1.19). CONSORT adoption had less effect on reporting of participant flow (RR, 1.14; 95% CI, 0.89-1.46) and blinding of participants (RR, 1.09; 95% CI, 0.84-1.43) or data analysts (RR, 5.44; 95% CI, 0.73-36.87). In studies examining CONSORT-adopting journals before and after the publication of CONSORT, description of the method of sequence generation (RR, 2.78; 95% CI, 1.78-4.33), participant flow (RR, 8.06; 95% CI, 4.10-15.83), and total CONSORT items (standardised mean difference, 3.67 items; 95% CI, 2.09-5.25) were improved after adoption of CONSORT by the journal., Conclusions: Journal adoption of CONSORT is associated with improved reporting of RCTs.

Purpose: Negative studies provide valuable information. However, conducting studies with inadequate power is unethical and an inefficient use of resources. The purpose of this study was to determine the prevalence of negative studies with inadequate power in urological literature., Materials and Methods: The Journal of Urology, Urology and BJU International (formerly British Journal of Urology) from 1982 to 2002 were searched using the Ovid MEDLINE database. All clinical trials that contained the phrase "no difference" were identified. Data necessary for power calculation were extracted from applicable studies., Results: Of the 417 articles identified in the MEDLINE search, 127 were negative studies that contained enough information to be analyzed. There were 70 (55%) articles from The Journal of Urology, 35 (28%) from BJU International and 22 (17%) from Urology. Of the studies that used continuous variables 65% had adequate power (greater than 80%) to detect a 50% difference between groups and 32% had adequate power to detect a 25% difference. Of the studies that used dichotomous variables only 33% had adequate power to detect a 50% difference between groups and 23% had adequate power to detect a 25% difference. Levels of adequate power in negative studies did not improve over time (p = 0.258)., Conclusions: Many negative studies in urological literature are inconclusive because they lack adequate power to detect even large differences between groups. Inadequately powered studies often result in false conclusions that alter clinical behavior and deter further research. Therefore, it is imperative to consider power when interpreting literature. When designing future investigations power calculations should be performed to ensure sufficient patient recruitment to attain clinically meaningful results.

Objectives: Television viewing and physical inactivity increase the risk of obesity in youth. Thus, identifying new interventions that increase physical activity and reduce television viewing would be helpful in the prevention and treatment of pediatric obesity. This study evaluated the effects of open-loop feedback plus reinforcement versus open-loop feedback alone on physical activity, targeted sedentary behavior, body composition, and energy intake in youth., Methods: Thirty overweight or obese 8- to 12-year-old children were randomly assigned to an intervention (n = 14) or control group (n = 16). Participants wore accelerometers every day for 8 weeks and attended biweekly meetings to download the activity monitors. For children in the open-loop feedback plus reinforcement (intervention) group, accumulating 400 counts of physical activity on pedometers earned 1 hour of television/VCR/DVD time, which was controlled by a Token TV electronic device. Open-loop feedback control subjects wore activity monitors but had free access to targeted sedentary behavior., Results: Compared with controls, the open-loop feedback plus reinforcement group demonstrated significantly greater increases in daily physical activity counts (+65% vs +16%) and minutes per day of moderate-to-vigorous physical activity (+9.4 vs +0.3) and greater reductions in minutes per day spent in television viewing (-116.1 vs +14.3). The intervention group also showed more favorable changes in body composition, dietary fat intake, and energy intake from snacks compared with controls. Reductions in sedentary behavior were directly related to reductions in BMI, fat intake, snack intake, and snack intake while watching television., Conclusions: Providing feedback of physical activity in combination with reinforcing physical activity with sedentary behavior is a simple method of modifying the home environment that may play an important role in treating and preventing child obesity.

Background: Procedural pain relief is sub-optimal in infants, especially small and vulnerable ones. Tetracaine gel 4% (Ametop, Smith-Nephew) provides pain relief in children and larger infants, but its efficacy in smaller infants and for peripherally inserted central catheters (PICC) remains uncertain. The objective of this trial was to assess the safety and efficacy of tetracaine gel on the pain response of very low birth weight (VLBW) infants during insertion of a PICC., Methods: Medically stable infants greater than or equal to 24 weeks gestation, requiring a non-urgent PICC, were included. Following randomization and double blinding, 1.1 g of tetracaine or placebo was applied to the skin for 30 minutes. The PICC was inserted according to a standard protocol. Pain was assessed using the Premature Infant Pain Profile (PIPP). A 3-point change in the pain score was considered clinically significant, leading to a sample size of 54 infants, with 90% statistical power. Local skin reactions and immediate adverse cardiorespiratory events were noted. The primary outcome, PIPP score at 1 minute, was analysed using an independent Student's t-test., Results: Fifty-four infants were included, 27 +/- 2 weeks gestation, 916 +/- 292 grams and 6.5 +/- 3.2 days of age. Baseline characteristics were similar between groups. The mean PIPP score in the first minute was 10.88 in the treatment group as compared to 11.74 in the placebo group (difference 0.86, 95% CI -1.86, 3.58). Median duration of crying in non-intubated infants was 181 seconds in the tetracaine group compared to 68 seconds in the placebo group (difference -78, 95% CI -539, 117). Local skin erythema was observed transiently in 4 infants (3 in the treatment and 1 in the placebo group). No serious harms were observed., Conclusion: Tetracaine 4% when applied for 30 minutes was not beneficial in decreasing procedural pain associated with a PICC in very small infants.

Objective: Wrist buckle fractures are a frequent reason for emergency department visits. Although textbooks recommend 2 to 4 weeks of immobilization in a short arm cast, management varies. Treatment with both casts and splints is common, and length of immobilization varies. The objective was to determine if children with distal radius and/or ulna buckle fractures treated with a removable splint have better physical functioning than those treated with a short arm cast for 3 weeks., Methods: This was a randomized, controlled trial in the emergency department of an academic, tertiary care children's hospital. Participants were children 6 to 15 years of age with distal radius and/or ulna buckle fractures who were randomly assigned to treatment with a short arm cast for 3 weeks or a removable splint. Cast removal was at 3 weeks. A validated self-reported outcome tool, the Activities Scales for Kids performance version (ASKp), was used to measure physical functioning over a 4-week period. The main outcome was the ASKp score at 14 days postinjury., Results: We randomly assigned 113 patients, and 87 were included in the final analysis: 42 in the splint group and 45 in the cast group. Study groups were similar in age, gender, bone fractured, and dominant hand injured. There were significant differences in ASKp score at day 14 and change in ASKp from baseline at days 14 and 20, indicating better functioning in the splint group. Splinted children had less difficulty with bathing throughout the entire study. There were no significant differences in pain between groups as measured by visual analog scale. There were no refractures., Conclusions: Children treated with removable splinting have better physical functioning and less difficulty with activities than those treated with a cast.

Objectives: The aim of this study was to examine the measurement properties of the Test of Visual-Perceptual Skills-Revised (TVPS-R)., Methods: A group of 356 typically developing children 5-11 years of age completed the TVPS-R along with three criterion measures., Results: Several of the TVPS-R items had item-total subscale correlation coefficients were lower than the 0.20 correlation criteria. Cronbach's alpha coefficients varied between 0.74 and 0.84 for the seven subscales. The perceptual quotient (PQ) reliability coefficient for the age levels ranged between 0.79 and 0.91. The PQ total group reliability coefficient was 0.96. Results from the principal component analysis indicated that the majority of the TVPS-R items loaded on a dominant first factor. Confirmatory factor analytic models were assessed using four different goodness-of-fit indices. Two of the fit indices supported the unidimensional assumption (RMR and CFI ), while two of the fit indices did not support the TVPS-R one-factor model (chi-square and RMSEA). A unitary motor-free visual-perceptual factor was not found., Conclusion: The TVPS-R PQ should not be used as an overall performance summary score. Of the seven TVPS-R subscales, five can be used with confidence (visual discrimination, visual-spatial relationships, visual-sequential memory, visual figure ground, and visual-closure) whereas the visual memory and visual form constancy [corrected] subscales are not recommended.

Objective: To determine whether vulnerability factors (confidence with breastfeeding, postpartum depression, supplementation, and perceived adequacy of support) are associated with breastfeeding outcome at 6 weeks postpartum after controlling for age and education., Design: Secondary analysis of a cross-sectional telephone survey at 6 weeks postpartum., Setting: Ottawa-Carleton, Ontario, Canada., Participants: A proportionate, consecutive sample of breastfeeding women from each of four hospitals in the region (526/554, 95% response rate)., Methods: Stratified bivariate analyses were used to examine the relationship between each factor and breastfeeding outcome. Multivariate logistic regression analyses examined relationships between all factors and breastfeeding outcome., Results: In the logistic regression analyses, confidence with breastfeeding (odds ratio: 1.85, 95% confidence interval: 1.50-2.27, p < .001) and postpartum depression (odds ratio: 0.28, 95% confidence interval: 0.11-0.71, p= .007) were related to breastfeeding after controlling for age and education., Conclusions: Support for breastfeeding should include assessment of maternal confidence with breastfeeding and postpartum depression. Evaluation of intervention strategies to address these vulnerability factors is a priority.

Background: Coagulase negative staphylococcus (CONS) is the main cause of late-onset sepsis in Neonatal Intensive Care Units (NICU). Although CONS rarely causes fulminant sepsis, vancomycin is frequently used as empiric therapy. Indiscriminate use of vancomycin has been linked to the emergence of vancomycin resistant organisms. The objective of this study was to compare duration of CONS sepsis and mortality before and after implementation of a policy of selective vancomycin use and compare use of vancomycin between the 2 time periods., Methods: A retrospective study was conducted of infants > or =4 days old, experiencing signs of sepsis with a first positive blood culture for CONS, during two 12-month periods. Late-onset sepsis was treated empirically with vancomycin and gentamicin during period 1, and cloxacillin and gentamicin during period 2. The confidence interval method was used to assess non-inferiority of the outcomes between the two study groups., Results: There were 45 episodes of CONS sepsis during period 1 and 37 during period 2. Duration of sepsis was similar between periods (hazard ratio of 1.00, 95%CI: 0.64, 1.57). One death during period 2 was possibly related to CONS sepsis versus none in period 1. Vancomycin was used in 97.8% of episodes in period 1 versus 81.1% of episodes in period 2., Conclusion: Although we failed to show non-inferiority of duration of sepsis in the cloxacillin and gentamicin group compared to the vancomycin and gentamicin group, duration of sepsis was clinically similar. Restricting vancomycin for confirmed cases of CONS sepsis resistant to oxacillin appears effective and safe, and significantly reduces vancomycin use in the NICU.

Objectives: To determine incidence, outcomes, and risk factors for pediatric cerebral edema with diabetic ketoacidosis (CEDKA) in Canada., Study Design: This was a case-control study nested within a population-based active surveillance study of CEDKA in Canada from July 1999 to June 2001. Cases are patients with DKA <16 years of age with cerebral edema. Two unmatched control subjects per case are patients with DKA without cerebral edema., Results: Thirteen cases of CEDKA were identified over the surveillance period for an incidence rate of 0.51%; 23% died and 15% survived with neurologic sequelae. CEDKA was present at initial presentation of DKA in 19% of cases. CEDKA was associated with lower initial bicarbonate ( P = .001), higher initial urea ( P = .001), and higher glucose at presentation ( P = .014). Although there was a trend to association with higher fluid rates and treatment with bicarbonate, these were not independent predictors., Conclusions: CEDKA remains a significant problem with a high mortality rate. No association was found between the occurrence of CEDKA and treatment factors. The presence of cerebral edema before treatment of DKA and the association with severity of illness suggest that prevention of DKA is the key to avoiding this devastating complication.

Background and Objectives: Low level laser therapy (LLLT) offers promising symptomatic relief of osteoarthritic (OA) pain. We examined efficacy of active LLLT versus sham LLLT on finger joints and three superficial nerves., Study Design/materials and Methods: OA-patients randomly assigned, received three treatments per week for 6 weeks of LLLT (n = 42) or sham LLLT (n = 46)., Results: Pain relief, morning stiffness, and functional status did not significantly improve for LLLT versus placebo. No significant differences were found in finger range of motion, except carpometacarpal opposition (P = 0.011), grip strength, and patient global assessment which improved for active LLLT participants (P = 0.041)., Conclusions: LLLT is no better than placebo at reducing pain, morning stiffness, or improving functional status for OA-hand patients., (Copyright 2005 Wiley-Liss, Inc.)

Objectives: Debate continues with respect to a "watch and wait" approach versus immediate antibiotic treatment for the initial treatment of acute otitis media. In this double-blind noninferiority trial, we compared clinical improvement rates at 14 days for children (6 months to 5 years of age) with acute otitis media who were randomly assigned to receive amoxicillin or placebo., Methods: We enrolled healthy children who presented to clinics or the emergency department with a new episode of acute otitis media during the fall and winter months in Ottawa (from December 1999 to the end of March 2002). The children were randomly assigned to receive amoxicillin (60 mg/kg daily) or placebo for 10 days. Telephone follow-up was performed on each of days 1, 2 and 3 and once between day 10 and day 14. The primary outcome was clinical resolution of symptoms, defined as absence of receipt of an antimicrobial (other than the amoxicillin in the treatment group) at any time during the 14-day period. Secondary outcomes were the presence of pain and fever and the activity level in the first 3 days, recurrence rates, and the presence of middle ear effusion at 1 and 3 months., Results: According to clinical scoring, 415 of the 512 children who could be evaluated had moderate disease. At 14 days 84.2% of the children receiving placebo and 92.8% of those receiving amoxicillin had clinical resolution of symptoms (absolute difference -8.6%, 95% confidence interval -14.4% to -3.0%). Children who received placebo had more pain and fever in the first 2 days. There were no statistical differences in adverse events between the 2 groups, nor were there any significant differences in recurrence rates or middle ear effusion at 1 and 3 months., Interpretation: Our results did not support the hypothesis that placebo was noninferior to amoxicillin (i.e., that the 14-day cure rates among children with clinically diagnosed acute otitis media would not be substantially worse in the placebo group than the treatment group). Nevertheless, delaying treatment was associated with resolution of clinical signs and symptoms in most of the children.

Background: Child maltreatment is prevalent in Canadian society, and medical professionals are frequently required to provide care in these cases. Physician knowledge and training in child protection have been questioned. This study examined the experience, perceived adequacy of training, and perceived competency of Canadian pediatric residents in child protection., Methods: Structured questionnaires were sent to child protection program directors (CPPDs), pediatric program directors (PPDs) and pediatric residents at the 16 Canadian pediatric academic centers. Data were analyzed using descriptive statistics, chi(2)-analyses, a Mann-Whitney test, and linear regression., Results: Responses were obtained from 15 of 16 CPPDs, all 16 PPDs, and 190 of 348 (54.6%) residents. All programs provided didactic teaching sessions. Only 3 programs had mandatory clinical rotations, 9 programs offered clinical electives, and 7 programs did not offer any specific clinical experience in child protection. Half of the residents had seen 5 or fewer cases of maltreatment. Residents and program directors most commonly rated the training as "somewhat adequate, needs improvement" with a significant minority rating it as "poor, inadequate." Residents' self-rating of competency was positively associated with number of years of training and number of cases of maltreatment seen. Almost all residents (92%) felt that they needed further training in child protection, including 85% of graduating residents. Some of the residents (16.4%) did not anticipate dealing with child protection cases as practicing pediatricians., Conclusions: Canadian pediatric residents receive little exposure and limited training in child abuse and neglect. As a result, even senior pediatric residents feel poorly trained. These results highlight the need to establish effective training programs for residents in child protection.

Rapid respiratory syncytial virus (RSV) diagnosis is vital to the prevention of nosocomial RSV infections. We evaluated a new rapid lateral-flow RSV immunoassay, the QuickLab RSV test, that requires use of only one reagent. We compared QuickLab to the Directigen RSV (DIR) assay, which requires six reagents, and direct fluorescent antibody (DFA) testing. DFA results were considered the "gold standard." For 133 nasopharyngeal aspirates tested, DFA results were 77 (57.8%) positive, 47 (35.3%) negative, and 9 (6.8%) indeterminate. The sensitivities, specificities, positive predictive values, and negative predictive values of QuickLab and DIR tests were 93.3% (70 of 75) and 80.8% (59 of 73), 95.6% (43 of 45) and 100.0% (46 of 46), 97.2% (70 of 72) and 100.0% (59 of 59), and 89.6% (43 of 48) and 76.7% (46 of 60), respectively. QuickLab was significantly (P = 0.02) more sensitive than DIR; the difference in specificities was not significant. DFA was more sensitive than DIR (P < 0.001) but not more sensitive than QuickLab (P = 0.45). The results of DIR testing were initially uninterpretable and required retesting with 15% of the specimens compared to 3% of QL results (P < 0.001). We conclude that the QuickLab RSV test has sensitivity similar to that of the DFA assay and better than that of the DIR assay. QuickLab testing is also simpler to perform and interpret than both DFA and DIR testing.

Several outcome tools have been developed to measure physical functioning in pediatric orthopedic patients. One such tool, the Activities Scale for Kids (ASK), allows assessment of physical functioning in the community in 5- to 15-year-olds. Previous validation of the ASK showed a significant difference in scores according to global ratings of disability. In this study, the ASK was administered to children without musculoskeletal disability to determine how normal respondents scored. ASK questionnaires were distributed to 137 children and 122 (89%) were returned. Normal children scored quite high, with a mean summary score of 93.12 (SD 6.45). This score differs significantly from the mean summary score for children with mild disabilities as determined in previous studies of disability (P = 0.005).

Objective: To determine whether physicians can estimate accurately the age of an accidental bruise on direct physical examination., Methods: Children who presented to the emergency department of a children's hospital with accidental bruises of known age and origin had demographic data and information about their injury recorded. History-blinded emergency pediatricians, other physicians, and trainees (fellows, residents, and medical students) independently examined the bruised area and recorded injury characteristics and age estimation and ranked characteristics that influenced their estimation., Results: Fifty children with accidental bruises were enrolled. Emergency pediatricians' accuracy of age estimation within 24 hours of actual age was 47.6%. Individual emergency pediatrician's accuracy ranged from 0% to 100%, and the interobserver reliability was poor (kappa = -0.03). Accuracy within 24 hours of actual age was 29.4% for other physicians and 36.8% for trainees, which was similar to the emergency pediatricians. Observers reported using color primarily to estimate age, followed by tenderness and then swelling; however, none of these factors was significantly correlated with accuracy., Conclusions: Physician estimates of bruise age are highly inaccurate within 24 hours of the actual age of the injury. Large individual variability and poor interrater reliability also suggest that caution must be used when interpreting these estimates. This study supports earlier studies, urging extreme caution in estimating bruise age, even when such estimates are based on direct examination of the injured area.

The seasonal variation in concentrations of maternal serum antibodies to respiratory syncytial virus fusion protein was investigated with the use of 761 maternal sera at delivery of term infants during a 12-month period. Mean antibody titers were significantly higher between April and September and significantly higher in women who already had children at home.

Following the launch of a publicly funded influenza immunization program for all residents of Ontario over the age of 6 months, we evaluated 203 parents of children who presented to our emergency department between January and March of the following year (2001). Overall, 54 (27%) of the children had been vaccinated. Parents of non-immunized children were more likely to believe that immunization resulted in a flu-like illness (42% v. 17%; p = 0.001), caused side effects that were more severe than having influenza (36% v. 17%; p = 0.010) and weakened the immune system (52% v. 24%; p < 0.001). Parents of both immunized and non-immunized children incorrectly identified gastrointestinal symptoms as symptoms of influenza. The primary reason for deciding against immunization was the belief that their child was not at risk. After adjustment, children with a chronic disease were more likely than those without a chronic disease to be immunized (adjusted odds ratio [OR] 4.7, 95% confidence interval [CI] 1.8-12.6). Children of parents who discussed immunization with a physician were more likely to be immunized than those who had not discussed immunization with a physician (OR 6.8, 95% CI 2.4-19.2).

Background: Acute hematogenous osteomyelitis (AHO) occurs primarily in children and is believed to evolve from bacteremia followed by localization of infection to the metaphysis of bones. Currently, there is no consensus on the route and duration of antimicrobial therapy to treat AHO., Methods: We conducted a systematic review of a short versus long course of treatment for AHO due primarily to Staphylococcus aureus in children aged 3 months to 16 years. We searched Medline, Embase and the Cochrane trials registry for controlled trials. Clinical cure rate at 6 months was the primary outcome variable, and groups receiving less than 7 days of intravenous therapy were compared with groups receiving one week or longer of intravenous antimicrobials., Results: 12 eligible prospective studies, one of which was randomized, were identified. The overall cure rate at 6 months for the short course of intravenous therapy was 95.2% (95% CI = 90.4 - 97.7) compared to 98.8% (95% CI = 93.6, 99.8) for the longer course of therapy. There was no significant difference in the duration of oral therapy between the two groups., Conclusions: Given the potential increased morbidity and cost associated with longer courses of intravenous therapy, this finding should be confirmed through a randomized controlled equivalence trial

Objective: To evaluate the quality of reports of complementary and alternative medicine (CAM) randomized controlled trials (RCTs) in the pediatric population. We also examined whether there was a change in the quality of reporting over time., Methods: We used a systematic sample of 251 reports of RCTs that used a CAM intervention. The quality of each report was assessed using the number of CONSORT checklist items included, the frequency of unclear allocation concealment, and a 5-point quality assessment instrument., Results: Nearly half (40%) of the CONSORT checklist items were included in the reports, with an increase in the number of items included. The majority (81.3%) of RCTs reported unclear allocation concealment with no significant change over time. The quality of reports achieved approximately 40% of their maximum possible total score as assessed with the Jadad scale with no change over time. Information regarding adverse events was reported in less than one quarter of the RCTs (22%) and information regarding costs was mentioned in only a minority of reports (4%)., Conclusions: RCTs are an important tool for evidence based health care decisions. If these studies are to be relevant in the evaluation of CAM interventions it is important that they are conducted and reported with the highest possible standards. There is a need to redouble efforts to ensure that children and their families are participating in RCTs that are conducted and reported with minimal bias. Such studies will increase their usefulness to a board spectrum of interested stakeholders.