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Objective: To discuss pediatric intensivist-driven ultrasound and the exigent need for research and practice definitions pertaining to its implementation within pediatric critical care, specifically addressing issues in ultrasound-guided vascular access and intensivist-driven echocardiography., Conclusions: Intensivist-driven ultrasound improves procedure safety and reduces time to diagnosis in clinical ultrasound applications, as demonstrated primarily in adult patients. Translating these applications to the PICU requires thoughtful integration of the technology into practice and would best be informed by dedicated ultrasound research in critically ill children.

Background: Although the costs of next generation sequencing technology have decreased over the past years, there is still a lack of simple-to-use applications, for a comprehensive analysis of RNA sequencing data. There is no one-stop shop for transcriptomic genomics. We have developed MAP-RSeq, a comprehensive computational workflow that can be used for obtaining genomic features from transcriptomic sequencing data, for any genome., Results: For optimization of tools and parameters, MAP-RSeq was validated using both simulated and real datasets. MAP-RSeq workflow consists of six major modules such as alignment of reads, quality assessment of reads, gene expression assessment and exon read counting, identification of expressed single nucleotide variants (SNVs), detection of fusion transcripts, summarization of transcriptomics data and final report. This workflow is available for Human transcriptome analysis and can be easily adapted and used for other genomes. Several clinical and research projects at the Mayo Clinic have applied the MAP-RSeq workflow for RNA-Seq studies. The results from MAP-RSeq have thus far enabled clinicians and researchers to understand the transcriptomic landscape of diseases for better diagnosis and treatment of patients., Conclusions: Our software provides gene counts, exon counts, fusion candidates, expressed single nucleotide variants, mapping statistics, visualizations, and a detailed research data report for RNA-Seq. The workflow can be executed on a standalone virtual machine or on a parallel Sun Grid Engine cluster. The software can be downloaded from http://bioinformaticstools.mayo.edu/research/maprseq/.

We have created an improved xenon interatomic potential for use with existing UO2 potentials. This potential was fit to density functional theory calculations with the Hubbard U correction (DFT + U) using a genetic algorithm approach called iterative potential refinement (IPR). We examine the defect energetics of the IPR-fitted xenon interatomic potential as well as other, previously published xenon potentials. We compare these potentials to DFT + U derived energetics for a series of xenon defects in a variety of incorporation sites (large, intermediate, and small vacant sites). We find the existing xenon potentials overestimate the energy needed to add a xenon atom to a wide set of defect sites representing a range of incorporation sites, including failing to correctly rank the energetics of the small incorporation site defects (xenon in an interstitial and xenon in a uranium site neighboring uranium in an interstitial). These failures are due to problematic descriptions of Xe-O and/or Xe-U interactions of the previous xenon potentials. These failures are corrected by our newly created xenon potential: our IPR-generated potential gives good agreement with DFT + U calculations to which it was not fitted, such as xenon in an interstitial (small incorporation site) and xenon in a double Schottky defect cluster (large incorporation site). Finally, we note that IPR is very flexible and can be applied to a wide variety of potential forms and materials systems, including metals and EAM potentials.

The present study aimed to quantify the magnitude of sex differences in humans' ability to accurately recognise non-verbal emotional displays. Studies of relevance were those that required explicit labelling of discrete emotions presented in the visual and/or auditory modality. A final set of 551 effect sizes from 215 samples was included in a multilevel meta-analysis. The results showed a small overall advantage in favour of females on emotion recognition tasks (d=0.19). However, the magnitude of that sex difference was moderated by several factors, namely specific emotion, emotion type (negative, positive), sex of the actor, sensory modality (visual, audio, audio-visual) and age of the participants. Method of presentation (computer, slides, print, etc.), type of measurement (response time, accuracy) and year of publication did not significantly contribute to variance in effect sizes. These findings are discussed in the context of social and biological explanations of sex differences in emotion recognition.

Theory and research emphasize differences in men's and women's sexual and romantic attitudes, concluding that men have stronger preferences for sexual than romantic stimuli as compared to women. However, most of the research on gender differences have relied on self-reports, which are plagued by problems of social desirability bias. The current study assessed young men's and women's implicit attitudes toward sexual and romantic stimuli to test whether, in fact, men have a stronger preference for sexual over romantic stimuli compared to women. We also assessed associations between implicit and explicit attitudes, as well as sex role ideology and personality. College students (68 men and 114 women) completed an Implicit Association Test (IAT) that assessed strengths of associations of sexual and romantic stimuli to both pleasant and unpleasant conditions. Results revealed that both men and women more strongly associated romantic images to the pleasant condition than they associated the sexual images to the pleasant condition. However, as predicted, women had a stronger preference toward romantic versus sexual stimuli compared to men. Our study challenges a common assumption that men prefer sexual over romantic stimuli. The findings indicate that measures of implicit attitudes may tap preferences that are not apparent in studies relying on self-reported (explicit) attitudes.

Complications of portal hypertension in children lead to significant morbidity and are a leading indication for consideration of liver transplantation. Approaches to the management of sequelae of portal hypertension are well described for adults and evidence-based approaches have been summarized in numerous meta-analyses and conferences. In contrast, there is a paucity of data to guide the management of complications of portal hypertension in children. An international panel of experts was convened on April 8, 2011 at The Children's Hospital of Pittsburgh of UPMC to review and adapt the recent report of the Baveno V Consensus Workshop on the Methodology of Diagnosis and Therapy in Portal Hypertension to the care of children. The opinions of that expert panel are reported., (© 2012 John Wiley & Sons A/S.)

Recent published data suggest that the prevalence of atopic dermatitis (AD) in African American children is significantly higher than in Caucasians. There are certain characteristics in the presentation of AD in African Americans that seem to differ from those in other racial groups, but there is a paucity of information on this topic. In this review, we highlight the differences in pathophysiology, clinical presentation, and treatment of AD between African Americans and Caucasians. It is important for dermatologists to understand these differences in order to provide better care for African American children with AD., (© 2012 Wiley Periodicals, Inc.)

Stakeholders are increasingly involved in species conservation. We sought to understand what features of a participatory conservation program are associated with its ecological and social outcomes. We conducted a case study of the management of invasive vertebrates in Australia. Invasive vertebrates are a substantial threat to Australia's native species, and stakeholder participation in their management is often necessary for their control. First, we identified potential influences on the ecological and social outcomes of species conservation programs from the literature. We used this information to devise an interview questionnaire, which we administered to managers of 34 participatory invasive-vertebrate programs. Effects of invasive species were related to program initiator (agency or citizen), reasons for use of a participatory approach, and stakeholder composition. Program initiator was also related to the participation methods used, level of governance (i.e., governed by an agency or citizens), changes in stakeholder interactions, and changes in abundance of invasive species. Ecological and social outcomes were related to changes in abundance of invasive species and stakeholder satisfaction. We identified relations between changes in the number of participants, stakeholder satisfaction, and occurrence of conflict. Potential ways to achieve ecological and social goals include provision of governmental support (e.g., funding) to stakeholders and minimization of gaps in representation of stakeholder groups or individuals to, for example, increase conflict mitigation. Our findings provide guidance for increasing the probability of achieving ecological and social objectives in management of invasive vertebrates and may be applicable to other participatory conservation programs., (©2012 Society for Conservation Biology.)

Objective: To conduct a meta-analysis of the rates of serious infection and malignancy in patients with early rheumatoid arthritis (RA) who have started anti-tumor necrosis factor (anti-TNF) therapy and had not received treatment with disease-modifying antirheumatic drugs (DMARDs) or methotrexate (MTX)., Methods: A systematic literature search was conducted through the summer of 2009. All studies included were randomized, double-blind, placebo-controlled trials involving patients with early RA who were started on anti-TNF therapy without prior DMARD/MTX use. Six trials met the inclusion criteria for the meta-analysis, comprising a total of 2,183 patients receiving biologic therapy and 1,236 patients receiving MTX. The data extracted were from published trials., Results: A pooled odds ratio (OR) (determined using Mantel-Haenszel methods, with a continuity correction designed for sparse data) was calculated for serious infections (requiring hospitalization) and malignancies, comparing anti-TNF therapy to MTX control. The pooled OR for serious infections was 1.28 (95% confidence interval [95% CI] 0.82-2.00) and that for malignancies was 1.08 (95% CI 0.50-2.32). There was no significant difference in either the rate of serious infections or the rate of malignancies between the anti-TNF therapy group and the control group., Conclusion: Whereas other meta-analyses have shown an increased risk of serious infection and malignancy in patients receiving anti-TNF therapy, the results of the present meta-analysis show that there is not an increased risk when the patients have early disease and have not previously been treated with DMARDs and/or MTX., (Copyright © 2011 by the American College of Rheumatology.)

Objectives: Accurate communication of information concerning the risks and benefits of medications is essential for adherence and patient safety. A diverse array of information and sources makes it difficult to know exactly what to tell a patient with rheumatoid arthritis about methotrexate., Objective: Our objective is to determine what key information patients must know about methotrexate and the key reasons they should call their doctor while they are taking methotrexate., Methods: Three hundred and forty-four Canadian rheumatologists were sent a survey containing open-ended questions to gain uncued narrative perspectives from each individual's experience. The survey was designed to determine what must all patients taking methotrexate know and when must patients taking methotrexate call a physician? Emergent coding was used to establish a set of categories to form a checklist for coding. A second member checking survey was sent to gain confirmation and validation of themes developed from the initial survey., Results: One hundred and seventy out of 344 (49.5%) surveys were completed. Regular blood testing, once weekly dosing, risk of infection, pregnancy and lactation information, alcohol limitation, potential lung toxicity, and drug interactions were thought to be important. Patients should call if they became pregnant, developed symptoms suggestive of lung toxicity, developed an infection, severe mouth sores, or were concerned about any side effects warranting the discontinuation of the medication., Conclusions: This study is the first to describe, from a rheumatologist's perspective, the key important information that all patients should know and when patients should call their doctor when taking methotrexate.

Objective: With continuing use of the Internet, rheumatologists are referring patients to various websites to gain information about medications and diseases. Our goal was to develop and evaluate a Medication Website Assessment Tool (MWAT) for use by health professionals, and to explore the overall quality of methotrexate information presented on common English-language websites., Methods: Identification of websites was performed using a search strategy on the search engine Google. The first 250 hits were screened. Inclusion criteria included those English-language websites from authoritative sources, trusted medical, physicians', and common health-related websites. Websites from pharmaceutical companies, online pharmacies, and where the purpose seemed to be primarily advertisements were also included. Product monographs or technical-based web pages and web pages where the information was clearly directed at patients with cancer were excluded. Two reviewers independently scored each included web page for completeness and accuracy, format, readability, reliability, and credibility. An overall ranking was provided for each methotrexate information page., Results: Twenty-eight web pages were included in the analysis. The average score for completeness and accuracy was 15.48+/-3.70 (maximum 24) with 10 out of 28 pages scoring 18 (75%) or higher. The average format score was 6.00+/-1.46 (maximum 8). The Flesch-Kincaid Grade Level revealed an average grade level of 10.07+/-1.84, with 5 out of 28 websites written at a reading level less than grade 8; however, no web page scored at a grade 5 to 6 level. An overall ranking was calculated identifying 8 web pages as appropriate sources of accurate and reliable methotrexate information., Conclusion: With the enormous amount of information available on the Internet, it is important to direct patients to web pages that are complete, accurate, readable, and credible sources of information. We identified web pages that may serve the interests of both rheumatologists and patients.

Background: To determine the efficacy of calcium channel blockers (CCBs) for primary Raynaud's phenomenon (RP). Primary outcomes were frequency and severity of RP attacks., Methods: A meta-analysis was conducted using primary data sources: Medline, Current Contents and the Cochrane Controlled Trials Register. Inclusion criteria were randomized controlled trials (RCTs) of >2 days' duration with <35% dropouts. Eighteen of 31 trials were eligible for inclusion [13 nifedipine vs placebo; five other CCBs vs placebo (n = 361)]. The main reasons for trial exclusion were: subset data (primary RP) not provided (n = 10); data published more than once (n = 1); lack of control group (n = 1); and lack of randomization (n = 1). Data were abstracted independently and a weighted mean difference (WMD) was calculated for the outcomes., Results: The WMD (95% confidence interval) of all CCBs vs placebo for reduction in the frequency of attacks (n = 17) over 1 week was -5.00 (-9.02, -0.99) (P = 0.01) or -2.80 (-3.90, -1.70) when heterogeneity was considered, and -6.05 (-11.19,-0.19) (P = 0.04) for nifedipine alone (n = 10). The WMD of all CCBs vs placebo (n = 8) for reduction in severity of attacks (assessed with a 10-cm visual analogue scale) was -1.39 (-2.20, -0.58) (P = 0.0007) and -1.81 (-3.08, -0.54) (P = 0.005) for nifedipine alone (n = 5)., Conclusions: Several small RCTs of CCBs for primary RP have been conducted and have yielded clinical improvement in the frequency and severity of ischaemic attacks. Most trials were crossover trials in which order effect was not studied; this may have introduced bias. The effect size may have been small because of low dosing in studies. The efficacy of CCBs for reducing severity and frequency of ischaemic attacks in primary RP is small (average of 2.8 to 5.0 fewer attacks per week and a 33% reduction in severity).

A range of halogenated aromatics and heteroaromatics bearing a primary amine group are shown to be suitable substrates for Suzuki cross-coupling reactions with arylboronic acids and pyridylboronic acids under standard conditions, without the need for protection/deprotection steps. New amino-substituted arylpyridines, bipyridines, and pyrazinopyridines have thereby been obtained. Conditions for the efficient syntheses of 2-methoxy-5-pyridylboronic acid 1 and 2-methoxy-3-pyridylboronic acid 2 in ca. 75 g batches have been defined. A 2-fold reaction of 2-amino-5-bromopyrazine with 2,5-dimethoxy-1,4-benzenediboronic acid affords 1,4-dimethoxy-2,5-bis[2-(5-aminopyrazyl)]benzene 31. The X-ray crystal structures of 1 and 31.DMF are reported.

Objective: To estimate the prevalence of scleroderma (systemic sclerosis, SSc) in 3 cities, Windsor, Sarnia, and Woodstock, Ontario, within our referral area, which has a referral base population of 1 million., Methods: To compare the addresses and exposures of referrals with SSc, we performed a case control study using our patients with scleroderma and 2 age and sex matched controls from the same rheumatologist's practice., Results: Sixty-seven of 91 patients with SSc and 87 of 154 controls responded. The mean age of patients with SSc was 53.2 years versus 52.8 years in controls. There was no statistically significant increase in the number of SSc patients from Windsor (population 197,694): 14 patients (15.4%) with SSc versus 18 controls (11.6%) (p < 0.41); or Sarnia (population 72,738): 7 patients (7.7%) with SSc versus 7 controls (4.5%) (p < 0.31). However, there were 9 cases (9.9%) from Woodstock (population 32,086) versus one control (0.64%) (p < 0.0004). The point prevalence of scleroderma was at least 0.71/10,000 in Windsor, 0.96/10,000 in Sarnia, and 2.8/10,000 in Woodstock. There were no significant between-group differences in exposure to industrial toxins or chemicals including vinyl chloride, silica, and benzene, but exposure rates in both groups were low. Occupations and proportion of those who were work disabled were not different. Patients with SSc were not more likely to have smoked cigarettes (p < 0.43); however, they were more likely to drink at least 6 drinks of alcohol per week (p < 0.04) and had more dental fillings (p < 0.05). Patients with SSc knew on average 3.2 others with this disease, and controls knew only 0.25 others with scleroderma (p < 0.00001). Two patients with SSc knew someone with SSc in their workplace versus none of the controls., Conclusion: Our a priori expected higher prevalence of scleroderma in Windsor and Sarnia did not reach significance, but the cluster in Woodstock seems statistically validated, and the exact reason for this cluster remains unclear. It is unlikely that all patients with SSc in Woodstock were seen by us, so the prevalence of scleroderma is at least 2.8/10,000, which is a medium to high prevalence compared to other studies. Associations with alcohol and dental fillings require further study.

There appears to be considerable symptomatic overlap between neuroleptic withdrawal reactions and the serotonin syndrome. This case report is of an 8-year-old boy who developed symptoms compatible with both conditions while discontinuing pimozide and starting fluoxetine. It illustrates how the use of neuroleptic medication in young children is not without the risk of serious adverse drug events and can complicate diagnostic issues. This case report supports the suggestion that adverse drug reactions related to neuroleptics and serotonergic agents could be part of the same clinical and neurophysiological spectrum.

Background: The incidence of postcoronary artery bypass graft (CABG) atrial fibrillation (AF) is 22.5% at the QEII Health Sciences Centre and the mean length of stay is 5.5 days greater than for those patients who do not experience this complication. Appropriate pharmacological management is important to prevent the potential morbidity from AF, such as thromboembolism, congestive heart failure, cardiogenic shock and coronary ischemia. This project compared current practice patterns in the management of post-CABG AF with local practice pattern beliefs and evidence from the primary literature. Subsequently, treatment guidelines were designed to help guide a rationale treatment approach., Objective: To promote appropriate treatment strategies for post-CABG AF and increase local practitioner awareness of drug-use outcomes by developing consensus treatment guidelines., Design: There were three phases. In phase 1, a retrospective chart analysis of 35 post-CABG AF patients over three consecutive months was conducted to assess current practice patterns. All published studies on this subject were also collected and analysed. A survey of pharmacological treatment preferences was distributed to local stakeholders during phase 2. The third phase involved the development and implementation of treatment guidelines., Results: This study identified a highly variable approach to the treatment of post-CABG AF. The mean number of agents used to treat AF post-CABG was two (range 1-4); all patients (100%) were prescribed rate-controlling agents and 37% were prescribed an antiarrhythmic drug. There was also a mismatch between practice pattern beliefs and actual practice., Conclusions: This reinforced the need for a consistent treatment approach that was facilitated with the development and implementation of local guidelines.

Bullying has serious long term consequences for all concerned. The cost of ignoring bullying is great, and it is no longer acceptable to view bullying as a normal part of everyday life that children have to learn to tolerate. Effective strategies exist to reduce the frequency of bullying and to make this type of aggressive behaviour less likely to occur.

Doctors are increasingly involved in child protection proceedings which consider whether emotional abuse has occurred. This may be a complex and difficult area, hindered by the paucity of consensus opinion and research in this area. This review suggests how doctors can assist in the decision-making process and outlines the management of children and adults who suffer sequelae of emotional abuse.

Objective: To review the literature addressing use of the pulmonary artery catheter (PAC) in pediatric patients., Data Source: All pertinent English language articles dealing with the use of pulmonary artery catheterization in pediatric patients were retrieved from 1979 through 1996., Study Selection: Articles were chosen for review if the use of pulmonary artery catheterization in pediatric patients was studied or reviewed., Data Extraction: From the articles selected, information was obtained about changes in diagnosis, therapy and outcome associated with PAC use in pediatric patients., Data Synthesis: The available literature suggests substantial value from the information made available by use of the PAC in a small group of critically ill infants and children., Conclusion: Until there is substantive evidence in children that outcome is negatively affected by their use, PACs should remain available. Experienced physicians should directly supervise PAC insertion and use.

The success rate and complications from femoral arterial and venous catheterization in infants and children in a university affiliate pediatric intensive care unit were determined prospectively over a 2-year period. We also performed a meta-analysis from published literature to determine the combined estimates of noninfectious and infectious complications (with 95% confidence limits) using the inverse variance-weighted method. Success rates were 94.5% and 94.4% for femoral arterial (n=110) and venous (n=89) catheterizations, respectively, and were related to operator expertise, age, and hemodynamic status. Median age was 2.4 years and 1.1 year for arterial and venous catheterizations, respectively. Immediate complications were hematoma (10.9% arterial, 16.8% venous) and minor bleeding (13.6% arterial, 13.5% venous). Decreased pulses occurred with 7.7% of arterial catheterizations, and lower limb swelling occurred in 9.5% of venous catheterizations. Vascular complications occurred only in infants and resolved within 7-14 days. Catheter-related infections occurred in 1.9% of arterial and 3.6% of venous catheterizations. The mean duration of catheterization was 5.3 days and 6.3 days with femoral arterial and venous catheterizations, respectively. Meta-analysis of published studies shows that the estimates for noninfectious complications were 5.0%, 10.1%, 1.1%, and 1.8% for femoral arterial, femoral venous, axillary arterial, and nonfemoral venous catheters, respectively. The estimates for catheter-related infection were 2.5%, 3.7%, and 3.0% for femoral arterial, femoral venous, and nonfemoral venous catheters, respectively. The meta-analytic estimates for complication rates from published literature are not significantly different from the rates observed in our study. Femoral arterial and venous catheterization in infants and children are safe with an expected high success rate and acceptably low complication rates.

Background: The assessment and management of childhood emotional abuse is of increasing importance in psychiatric practice. At present there are no consensus views about the definition of emotional abuse and information from research is limited., Method: Information about emotional abuse from the medical, psychological, social science and legal literature is summarised. Definitions and proposed mechanisms of damage are discussed. Current research data and an overview of childhood and adult sequelae are presented. Proposals for clinical and medico-legal practice are made., Results: Theoretical models of emotional abuse and its consequences are derived from theories of childhood psychological development. Empirical research is beginning to show that emotional abuse may have a profound effect on aspects of psychological development in children., Conclusions: The developmental theories and methods of assessment well established in psychiatry are useful approaches to the clinical assessment and further understanding of emotional abuse.

Objective: Extracorporeal membrane oxygenation (ECMO) has been used with increasing frequency in the treatment of acute respiratory failure in pediatric patients. Our objective in this study was to test the hypothesis that ECMO improves outcome in pediatric patients with acute respiratory failure., Design: Multicenter, retrospective cohort analysis., Setting: Forty one pediatric intensive care units participated in the study under the auspices of the Pediatric Critical Care Study Group., Patients: All pediatric patients admitted to the participating institutions with acute respiratory failure during 1991 were included. Patients with congenital heart disease, contraindications to ECMO, or incomplete data were excluded, yielding a data set of 331 patients from 32 hospitals., Interventions: Conventional mechanical ventilation, high-frequency ventilation, and extracorporeal membrane oxygenation., Measurements and Main Results: Multivariate logistic regression analysis was used to identify factors associated with survival. In a second analysis, pairs of ECMO and non-ECMO patients, matched by severity of disease and respiratory diagnosis, were compared. The use of ECMO (p = .0082), but not the use of high-frequency ventilation, was associated with a reduction in mortality. Other factors independently associated with mortality included oxygenation index (p < .0001), Pediatric Risk of Mortality score (PRISM) (p < .0001) and the Paco2 (p = .045). In 53 diagnosis- and risk-matched pairs, there was a significantly lower mortality rate (26.4% vs. 47.2%; p < .01) in the ECMO-treated patients. When all patients were stratified into mortality risk quartiles on the basis of oxygenation index and PRISM score, the proportion of deaths among ECMO-treated patients in the 50% to 75% mortality risk quartile was less than half the proportion in the non-ECMO treated patients (28.6% vs. 71.4% p < .05)> No effect was seen in the other quartiles., Conclusions: The use of ECMO was associated with an improved survival in pediatric patients with respiratory failure. The lack of association of outcome with treatment in the ECMO-capable hospital or with another tertiary technology (i.e. high-frequency ventilation) suggests that ECMO itself was responsible for the improved outcome. Further studies of this procedure are warranted but require broad-based multi-institutional participation to provide sufficient statistical power and sensitivity to demonstrate efficacy.

Objectives: To determine the prevalence of, and factors associated with, burnout among pediatric intensivists across a variety of practice settings., Design: A population-based survey, using a mailed questionnaire that included a previously validated Burnout Scale., Setting: Private and academic pediatric critical care practices., Participants: Respondents from among all members of the Pediatric Section of the Society of Critical Care Medicine and all physicians certified in pediatric critical care medicine by the American Board of Pediatrics., Measurements and Main Results: The questionnaire consisted of demographic items, variables noted in the literature as being associated with burnout (e.g., the individual's perception of how others valued their work, and the use of preventive measures such as regular exercise to relieve stress), and a validated Burnout Scale. The questionnaire also included questions pertaining to past training, practice of other primary specialties or subspecialties, practice settings, admission responsibilities, actual and preferred practice activities, total work effort, academic activities, and causes of stress at work. The Burnout Scale of Pines and Aronson is a self-diagnosis instrument, consisting of 21 questions using a 7-point frequency scale. The total Burnout Score represents an average of the scores for the individual components. Scores of < or = 3 in our study were classified as "not burned out." Scores of > 3 and < or = 4 were classified as "at risk." Scores of > 4 were classified as "burned out." A total of 883 questionnaires were mailed; 474 (56%) were respondent returns and 35 questionnaires could not be delivered. Primary analyses focused on the 389 respondent attending physicians presently practicing pediatric critical care medicine at the time of the survey. The average Burnout Score of these attending physicians was 3.1 +/- 0.8; 36% were classified as being at risk for burnout, and 14% were classified as burned out. There was no association between burnout status and the following work conditions: having fellows; having protected time for research and publications; frequency of being called at home; frequency of returning to the hospital when called at home; or call schedule. Respondents classified as burned out were significantly more likely than respondents who were classified as not burned out to feel that their work was not valued by others. Burned out respondents were less likely than respondents who were not burned out to give the following description: feeling very successful; feeling that their peers viewed them as very successful; feeling satisfied in their professional life; and routinely exercising or having some other outside interest., Conclusions: We found that a high degree of burnout exists in pediatric critical care medicine, with 50% of pediatric intensivists at risk or burned out. Overall, there was no association between Burnout Scores and training, practice specialties, or practice settings, nor was there an association with aspects of practice that are physically taxing. However, perceptions about the value of their work and feelings of success and satisfaction were highly associated with those respondents classified as burned out. Routine exercise (a strategy used by some for stress reduction) was associated with lower Burnout Scores. Further studies are necessary to evaluate the trends that we have reported and to identify causal factors.

Objective: To determine the utility of a disposable colorimetric end-tidal CO2 detector during pediatric cardiopulmonary resuscitation (CPR) for (1) confirming endotracheal tube (ETT) position, and (2) assessing the relationship between end-tidal CO2 recorded by this method and outcome of pediatric CPR., Design/setting: Prospective observations during CPR in a university children's hospital., Participants: Forty children (28 male, 12 female) aged 1 week to 10 years (25 children aged < or = 1 year, mean age 27.2 months, median 7 months), weighing 2.5 to 40 kg (31 children weighing < or = 15 kg, mean 10.94 kg, median 7 kg) who underwent a total of 48 endotracheal intubations during CPR., Methods: After intubation, ETT position was verified by usual clinical methods including direct visualization. The device was attached between the ETT and ventilation bag, the patient was manually ventilated, and a first reading was obtained. Any color change from purple (Area A, end-tidal CO2 < 0.5%) to tan or yellow (Area B or C, end-tidal CO2 > or = 0.5%) was considered to be positive for airway intubation. CPR was conducted as per Pediatric Advanced Life Support guidelines. A second reading was obtained when the decision to discontinue CPR was made., Results: All nine esophageal tube positions were correctly identified by the detector. Thirty-three of 39 tracheal tube positions were correctly identified (P < .001). For verifying ETT position, the device had a sensitivity of 84.6%, specificity of 100%, positive predictive value of 100%, and negative predictive value of 60%. Readings were obtained at the end of CPR in 25 patients. All 13 patients who regained spontaneous circulation and survived to ICU admission had a second reading in the C range, while none of the 12 patients with a second reading in the A or B range survived. Both the first and second end-tidal CO2 readings in the C range correlated significantly with short-term survival (P = .01 and P < .001, respectively). Two patients were eventually discharged from the hospital., Conclusions: During CPR a positive test confirms placement of the ETT within the airway, whereas a negative test indicates either esophageal intubation or airway intubation with poor or absent pulmonary blood flow and requires an alternate means of confirmation of tube position. The detector may be of prognostic value for return of spontaneous circulation and short-term survival.

Perfluorocarbon-associated gas exchange (PAGE) has been proposed for the treatment of lung diseases characterized by high alveolar surface tension. Perflubron (perfluorooctyl bromide, LiquiVent, Alliance Pharmaceutical Corp.) is a high purity medical grade perfluorocarbon suitable for PAGE. We studied PAGE using perflubron in normal piglets and in animal models of pulmonary disease (meconium aspiration syndrome, oleic acid infusion and gastric acid aspiration as models of ARDS, and neonatal respiratory distress syndrome). All animals were studied under anesthesia. PAGE was instituted by intratracheal instillation of a volume of perflubron (generally 30 ml/kg) that approximates a normal functional residual capacity of the lung. Arterial blood gases were measured at 15 minute intervals. FiO2 during PAGE was 1.0. In normal piglets, PaO2 fell from 543 torr (during conventional gas breathing) to 363 torr (during PAGE). However, in models of lung disease, PAGE significantly enhanced PaO2.

Objectives: a) to determine if continuous nebulization of albuterol is more effective than intermittent nebulization in the treatment of children with status asthmaticus and impending respiratory failure; b) to determine the effect of continuous nebulization and intermittent nebulization on duration of hospital stay and bedside respiratory therapy care., Design: Prospective, randomized study., Setting: A pediatric intensive care unit (ICU) in a university children's hospital., Patients: Seventeen pediatric asthmatic patients with severe status asthmaticus, with impending respiratory failure (Woods asthma score > or = 5), and without evidence of cardiac or other preexisting lung disease were admitted to the pediatric ICU. The patients were randomized to receive continuous nebulization (n = 9) or intermittent nebulization (n = 8) of albuterol., Interventions: The asthmatic patients were randomized into two groups. The continuous group received 0.3 mg/kg/hr of albuterol by continuous nebulization; the intermittent group received 0.3 mg/kg of albuterol over 20 mins every hour. All patients received aerosol therapy through the same delivery system., Measurements: Responses to therapy were evaluated by following asthma score, arterial blood gas values, hemodynamics, FIO2, and arterial oxygen saturation initially and at 30 mins, 1 hr, 2 hrs, 4 hrs, then every 4 hrs for a 24-hr time period. Patients were determined to no longer be in impending respiratory failure when their asthma score was < 5 for four consecutive hours. Electrocardiograms, serum electrolyte values, and creatine phosphokinase total and MB fraction values were obtained before and after treatment. Hospital stay and respiratory therapy time, in relative value units (one relative value unit = 10 mins) were analyzed from data collected from therapist bedside flow sheets., Results: The patient characteristics (demographics, hemodynamics, arterial blood gas values, asthma severity, corticosteroid use, theophylline, and beta 2-adrenergic receptor agonist administration) before entry into the study did not differ between groups. Patients in the continuous group improved more rapidly and were out of impending respiratory failure sooner than patients in the intermittent group (continuous group = 12 (median) hrs (range 4 to 24) vs. intermittent group = 18 (median) hrs (range 12 to 24; p = .03). Bedside respiratory therapy time evaluated by relative value units was less for patients who received continuous nebulization of albuterol (continuous group = 14 (median) relative value units (range 6 to 26) vs. intermittent group = 33 (median) relative value units (range 25 to 49; p = .001). Hospital stay was shorter for patients who received continuous nebulization of albuterol (continuous group = 80 [median] hrs [range 51 to 173] vs. intermittent group = 147 [median] hrs [range 95 to 256]; p = .043). Hemodynamics, serum potassium, and creatine phosphokinase concentrations did not differ before and after the study in either group., Conclusions: In children with impending respiratory failure due to status asthmaticus, continuous nebulization of albuterol is safe and results in more rapid clinical improvement than intermittent nebulization. Respiratory therapy required at the bedside and duration of hospital stay were substantially less for patients receiving continuous nebulization of albuterol, which suggests that continuous nebulization of albuterol is more cost effective than intermittent nebulization.

Two cases of Capgras' syndrome are described in which patients committed serious acts of violence towards family members who had become the subject of delusional misidentification. The cases illustrate some typical features of Capgras' syndrome including its potential for dangerousness. Intoxication with alcohol is proposed as a precipitant for violence in these patients.

Background: Conventional cardiopulmonary resuscitation (CPR) for cardiac arrest after open-heart surgery in children is often unsuccessful despite the ability to perform open-chest massage. The purpose of this study was to review our results with mechanical support as rescue therapy in children with sudden circulatory arrest after cardiac surgery., Methods and Results: From 1981 through 1991, we have used mechanical support with an extracorporeal membrane oxygenator (ECMO) circuit for cardiac support in 33 children. Eleven of the 33 patients (age, 15 +/- 7 months) suffered cardiac arrest intractable to conventional open-chest massage 39 +/- 15 hours after an open-heart procedure. The mean duration of CPR was 65 +/- 9 minutes until ECMO flow was started. ECMO support was continued for 112 +/- 8 hours. One patient had ECMO discontinued due to bleeding (survived); three were discontinued from ECMO and died from neurological complications; and one died of cardiac dysfunction. Sepsis on ECMO was seen in one patient (survived). Overall early survival was seven of 11 (64%) with one patient requiring heart transplantation due to irreversible cardiac dysfunction. One child died late (1 month) after ECMO support. There were no long-term sequelae in the survivors., Conclusions: We conclude that ECMO rescue in children with postcardiotomy cardiac arrest is a feasible option in selected patients even after prolonged CPR (as long as 60 minutes).

Critically ill children often require endotracheal intubation prior to transport to a medical center. Correct endotracheal tube placement and maintenance during transport are essential. The utility of a portable colorimetric end-tidal CO2 detector during transport of critically ill children was evaluated. Fifty-eight children with spontaneous circulation (aged 1 day to 12 years, weight 0.9 to 26 kg) who underwent 59 intubations during transport by ground (n = 31) or air (n = 27) were studied. Tube position was confirmed by physical examination, arterial blood gas values, or arterial oxygen saturation, and sometimes by chest radiography. The detector was attached and readings were obtained after intubation; readings were repeated if endotracheal tube position was rechecked during transport. Fifty-seven of 58 tracheal positions and the 1 esophageal tube position were correctly identified. One false-negative result occurred in a severely hypocarbic 900-g premature newborn. On each occasion that the detector was used en route, the endotracheal tube position was correctly identified. It is concluded that the end-tidal CO2 detector is a useful tool for confirming endotracheal tube position during transport of critically ill children weighing more than 2 kg who are not in cardiopulmonary arrest.

Objective: To determine whether abnormalities in lung mechanics detected in infants during the acute phase of meconium aspiration syndrome persist after treatment with extracorporeal membrane oxygenation (EMCO)., Design: Prospective, descriptive study. Prospective evaluation of airway function and lung mechanics during and after ECMO by pulmonary function testing at 1.8 +/- 0.5 days of EMCO (period 1), follow-up at 1.4 +/- 0.2 days (period 2), and 7.0 +/- 0.9 days (period 3) after decannulation from ECMO., Setting: Tertiary care neonatal/pediatric ICU., Patients: Twelve neonates undergoing ECMO treatment for severe meconium aspiration syndrome that was refractory to conventional mechanical ventilation., Interventions: Maximum expiratory flow-volume curves were studied with the deflation flow-volume curve technique, and compliance and resistance of the respiratory system were studied with partial passive flow-volume curves., Measurements and Main Results: Respiratory system compliance was the only index of respiratory mechanics that was significantly (p less than .05) improved (0.96 +/- 0.1 vs. 0.61 +/- 0.1 mL/cm H2O/kg) immediately after decannulation from ECMO compared with period 1. Clinically important (p less than .05) improvement in forced vital capacity (28.0 +/- 5.5 vs. 16.1 +/- 1.9 mL/kg), respiratory system compliance (1.01 +/- 0.2 vs. 0.61 +/- 0.1 mL/cm H2O/kg), and maximum expiratory flow at 25%/forced vital capacity (1.0 +/- 0.3 vs. 2.2 +/- 0.3) was evident only during period 3 compared with period 1., Conclusions: We conclude that improvements in the clinical condition and oxygenation, permitting successful decannulation from ECMO, are achieved before clinically important improvements in lung mechanics.

Study Objective: To examine the validity of a disposable, colorimetric end-tidal CO2 detector in verifying endotracheal tube (ETT) placement in infants and children., Design: The detector was studied prospectively in 151 intubations., Setting: Operating room, ICU, and emergency department of a children's hospital., Participants: One hundred thirty-seven children undergoing endotracheal intubation for anesthesia (52), respiratory support (76), or CPR (23)., Interventions: After endotracheal intubation, tube position was verified, the detector was attached, and readings were obtained., Measurements and Results: The detector correctly identified tube position (trachea, 124; esophagus, four) in all 120 patients who were not in cardiac arrest (P less than .01). In the cardiac arrest setting, all six esophageal intubations were correctly identified, but two of the 17 tracheal intubations were incorrectly interpreted as esophageal intubations (P less than .01)., Conclusion: The detector accurately identifies ETT position in children with spontaneous circulation who weigh more than 2 kg. During CPR, a positive test correctly indicates that the ETT is in the airway, but a negative result (suggesting esophageal placement) requires an alternate means of confirming ETT position.

Cf the 87 survivors of extracorporeal membrane oxygenation over a 10-year period, 67 participated in a follow-up study which included neurologic examination (n = 67), cognitive testing (n = 67), and audiologic assessment (n = 33). Matched control subjects for those older than 5 years were also evaluated. Outcome was defined as normal for cognitive scores greater than or equal to 85 and normal neurologic examination results, suspect for cognitive scores 70 through 84 or nonfocal neurologic findings such as hypertonia/hypotonia, and abnormal for cognitive scores less than 70 or abnormal neurologic examination results. Of the 10 school-aged children studied, 9 were normal and there were no differences in mean cognitive scores between subjects and controls (IQ subjects = 109 +/- 12 [SD], IQ controls = 107 +/- 13). For preschoolers aged 2.7 through 4.11 years, the mean cognitive score was 91 +/- 11 and 7 (70%) were normal. For infants 6 through 30 months, the mean cognitive score was 101 +/- 22 and 27 (57%) were normal. A total of 7 children (21% of those studied) had abnormal audiologic assessments. Three children demonstrated mild high-frequency and 4 moderately severe high-frequency sensorineural hearing loss which was bilateral in 3 and of undetermined laterality in 1. Abnormal neurodevelopmental outcome was significantly associated with cerebral infarction and chronic lung disease. Outcome was not related to demographic or perinatal variables, illness severity prior to extracorporeal membrane oxygenation, or underlying diagnosis. Neurodevelopmental outcome among survivors of extracorporeal membrane oxygenation in this series is consistent with previous reports of morbidity among neonates with severe respiratory failure treated conventionally.

Background and Methods: the most reliable methods for confirming endotracheal tube placement are direct visualization of passage through the vocal cords and documentation of CO2 in the expired gas. We evaluated the use of a disposable colorimetric CO2 detector for verifying endotracheal tube position in small animals. The end-tidal CO2 (Petco2) detector was tested in 11 piglets with the endotracheal tube sequentially in the trachea, the esophagus, the esophagus with a carbonated beverage in the stomach, the esophagus after bag-mask ventilation. Endotracheal tube position was confirmed in all cases by direct visualization and capnometry., Results: The Petco2 detector identified the tube placement accurately in all 54 (21 tracheal, 33 esophageal) intubations (p less than .001)., Conclusions: This disposable Petco2 detector is highly sensitive and specific for verifying endotracheal tube placement in this nonarrest piglet model.

In previous published accounts of silastic replacement arthroplasty of the M.P. joint of the finger in rheumatoid disease, dynamic splintage has been used for up to six months after operation to ensure correction of ulnar drift. We have investigated two methods of surgical correction in a prospective trial in consecutive patients. No dynamic splintage was used. Both resulted in correction of ulnar drift from an average of 34 degrees (maximum 92 degrees) to 8 degrees (maximum 32 degrees) in 86 fingers. The two methods both corrected ulnar drift well, but crossed intrinsic transfer gave a better range of active movement and is recommended as an alternative to dynamic splintage.

The results of 58 consecutive cases of pharyngolaryngo-oesophagectomy and pharyngogastric anastomosis are presented. The Grey Turner technique is used, but modified by adding bilateral chest drainage established by guidance from below the diaphragm and a jejunostomy. The immediate postoperative therapy management of hypocalcaemia with calcium gluconate and long term control with calciferol is described. An overall 3-year survival rate of 29 per cent has been obtained. Seven patients survived longer than 7 years, the longest living over 10 years. The authors conclude that, with careful management this technique is within the compass of competent surgeons with good facilities and should be the surgical treatment of choice for these difficult tumours.

An automated method for the assay of N-acetyl-beta-glucosaminidase in human urine is described and a normal range of urinary N-acetyl-beta-glucosaminidase activity is reported. The automated method has been used routinely over a twelve month period in two London hospitals for monitoring the excretion of N-acetyl-beta-glucosaminidase in renal transplant patients. The abnormal elevation of urinary N-acetyl-beta-glucosaminidase provides an early warning of rejection by indicating the presence of renal parenchymal damage. The automated assay of urinary N-acetyl-beta-glucosaminidase may also be used in screening for the presence of renal disease.

A comparison was made of two established tests to see which was the better indicator of rejection after renal transplantation. Daily urine samples were assayed for excretion of N-acetyl-beta-D-glucosaminidase (NAG) and fibrin degradation products (FDP). Twenty-five rejection episodes were studied in 19 patients. Both indicators tended to move in parallel. NAG was more often elevated in rejection, namely in 96% of rejection episodes as against 76% for FDP, FDP had the advantage of fewer false positive results and when it correctly indicated rejection its increase above the baseline was relatively greater than for NAG, NAG and FDP can both provide early warning of rejection. NAG is preferred for its ease of assay. Assays are performed daily and are of practical value in clinical management. The results of assays must be interpreted in conjunction with all relevant information.

Urinary N-acetyl-beta-D-glucosaminidase (NAG) activities were assayed in every urine void throughout 24 hours in 17 normal people and in four patients with renal disease. The variation in NAG activity due to changing rates of urine flow was almost eliminated by factoring enzyme activity by the urinary creatinine concentration. Random samples of urine may thus be used for assay. The results of NAG assay in 36 patients with acute and chronic renal diseases showed that NAG was a sensitive indicator of renal damage. This simple test may be valuable in detecting or monitoring renal disease.