RESUMEN
BACKGROUND: Pediatric cardiac care is costly and requires extensive resources. We studied the effect of clinical pathways on practice patterns and patient care outcomes in infants and children hospitalized for cardiac surgery. METHODS: In consecutive patients admitted for selected cardiac surgical procedures before (n = 69) and after (n = 173) implementation of clinical pathways, outcomes including hospital length of stay, days in the ICU, time to extubation, ordering of blood studies, costs, and readmissions were compared. Data were analyzed for each of five cardiac surgical procedures: repair of an atrial septal defect, repair of a ventricular septal defect, division of a patent ductus arteriosus, repair of tetralogy of Fallot, and neonatal arterial switch operation to correct transposition of the great arteries. RESULTS: A significant reduction in length of hospital stay, including days in the ICU (decreased 1 to 2 days per admission), was achieved after the clinical pathway was implemented. Reductions in average duration of mechanical ventilation ranged from 28% for repair of a ventricular septal defect to 63% for repair of tetralogy of Fallot. The number of blood studies ordered decreased 20% to 30%. A significant reduction in hospital costs for each procedure, ranging from 16% to 29%, was also achieved with no adverse effects on patients' outcomes. CONCLUSIONS: Use of clinical pathways with children hospitalized for cardiac surgery can shorten length of stay in the hospital, reduce use of resources, and improve cost-effectiveness with beneficial outcomes for patients.
Asunto(s)
Procedimientos Quirúrgicos Cardíacos/economía , Vías Clínicas , Cardiopatías/economía , Cardiopatías/cirugía , Pautas de la Práctica en Medicina , Niño , Preescolar , Vías Clínicas/economía , Femenino , Pruebas Hematológicas/economía , Humanos , Lactante , Recién Nacido , Unidades de Cuidado Intensivo Pediátrico , Tiempo de Internación/economía , Masculino , Evaluación de Procesos y Resultados en Atención de Salud , Pautas de la Práctica en Medicina/economía , Respiración Artificial/economía , Estados UnidosRESUMEN
Human immunodeficiency virus type 1 (HIV-1) isolates from perinatally infected infants and children were examined for syncytium-inducing (SI) capacity. All isolates from 14 infants < 1 year old had non-syncytium-inducing (NSI) HIV-1 phenotypes. Within their first year, 10 infants progressed to AIDS and 3 died. Of isolates from 26 children > 2 years old, 13 had SI HIV-1 phenotypes and 13 had NSI strains. Children with SI virus had significantly lower CD4+ cell counts standardized for age and were significantly older than those with NSI strains (P = .008 and .001, respectively); the effect of viral phenotype on CD4+ lymphocytes could not be detected independent of age. In another group, children with SI strains were more likely to show in vitro zidovudine resistance. Results suggest a biphasic response to HIV infection in children. Progression to AIDS may occur rapidly in infants with NSI HIV-1, but older children tend to have SI phenotypes and lower CD4+ lymphocyte counts and more often show zidovudine resistance.
Asunto(s)
Infecciones por VIH/microbiología , Infecciones por VIH/fisiopatología , VIH-1/fisiología , Linfocitos T CD4-Positivos/microbiología , Línea Celular , Niño , Preescolar , Femenino , Estudios de Seguimiento , Células Gigantes , Infecciones por VIH/tratamiento farmacológico , VIH-1/efectos de los fármacos , VIH-1/genética , Humanos , Recuento de Leucocitos , Masculino , Pruebas de Sensibilidad Microbiana , Fenotipo , Especificidad de la Especie , Zidovudina/farmacologíaRESUMEN
Phospholipid antibodies (lupus anticoagulant, cardiolipin) are associated with a syndrome of repeated fetal loss. Mothers with phospholipid antibodies are currently being treated with either prednisone, aspirin, or heparin to prevent fetal death. We describe a neonate whose mother had cardiolipin antibody and recurrent fetal loss and was treated with prednisone and aspirin. Thrombosis was noted in placental fetal vessels. Thromboses developed in the infant's aorta, left renal artery, middle cerebral artery, and superior sagittal sinus. Infants of phospholipid-positive mothers may have vascular thrombosis and should be carefully monitored for signs of thromboembolism.
Asunto(s)
Síndrome Antifosfolípido , Enfermedades del Prematuro , Complicaciones del Embarazo , Trombosis , Síndrome Antifosfolípido/diagnóstico , Síndrome Antifosfolípido/tratamiento farmacológico , Aspirina/uso terapéutico , Femenino , Humanos , Recién Nacido , Enfermedades del Prematuro/diagnóstico , Masculino , Prednisona/uso terapéutico , Embarazo , Complicaciones del Embarazo/diagnóstico , Complicaciones del Embarazo/tratamiento farmacológico , Trombosis/diagnósticoRESUMEN
Decreasing susceptibility to zidovudine (ZDV) has been described in persons infected with human immunodeficiency virus (HIV) type 1 who are receiving ZDV therapy. However, the clinical significance of decreased ZDV susceptibility remains unclear. In this study, HIV isolates obtained from children with symptomatic HIV infection treated with ZDV were monitored for their susceptibility to the antiretroviral agent and correlated with disease progression. Using a peripheral blood mononuclear cell-based assay to measure ZDV susceptibility, we evaluated HIV isolates from 19 children (mean age, 6.8 years; range, 5 months to 12 years) during ZDV therapy for susceptibility to ZDV. Of the 19 children studied, 10 continued to have susceptible HIV strains during ZDV treatment, and 9 acquired resistant viruses. All eight isolates from children without previous exposure to ZDV were initially susceptible. After a median of 11 months of ZDV therapy, three (38%) of these eight children had acquired resistant HIV strains (defined as ZDV susceptibility > or = 10 mumol/L). Children with resistant strains had worse clinical outcomes than children whose viruses remained susceptible, as determined by a 50% decline in absolute CD4+ cell counts after 1 year of treatment, failure to thrive, or death. Children with resistant viruses who were given alternative antiretroviral therapy frequently responded to the new treatment with improved growth and stabilization of their HIV-related disease. These data suggest that, in HIV-infected children, ZDV-resistant HIV strains are associated with diminished drug efficacy and more rapid disease progression.
Asunto(s)
Síndrome de Inmunodeficiencia Adquirida/tratamiento farmacológico , VIH-1/efectos de los fármacos , Zidovudina/antagonistas & inhibidores , Síndrome de Inmunodeficiencia Adquirida/inmunología , Síndrome de Inmunodeficiencia Adquirida/microbiología , Administración Oral , Linfocitos T CD4-Positivos/efectos de los fármacos , Niño , Preescolar , Farmacorresistencia Microbiana , Femenino , Proteína p24 del Núcleo del VIH/sangre , VIH-1/aislamiento & purificación , Humanos , Lactante , Recuento de Leucocitos/efectos de los fármacos , Masculino , Pruebas de Sensibilidad Microbiana/métodos , Factores de Tiempo , Resultado del Tratamiento , Zidovudina/administración & dosificaciónRESUMEN
Although perfluorooctylbromide (PFOB) is known to stimulate macrophages, particulates given intravenously (IV) can inhibit the body's response to infection by blocking the reticuloendothelial system. Since PFOB enhances abscesses on computed tomography (CT), the authors evaluated its safety and efficacy by assessing the mortality and abscess volume in 104 rabbits with intrahepatic abscesses given either PFOB or lactated Ringer's (LR), and by comparing its efficacy to that of 76% meglumine sodium diatrizoate (MSD76). Abscesses were produced by injecting a virulent strain of E. coli into the liver. Two days later, five of the rabbits had died. Of the remaining rabbits, 50 were given 5 g/kg PFOB IV, and 49 were given an equal volume of LR. All rabbits had a CT scan at four and at ten days after infusion. They were killed before the second CT scan. Thirty seconds before being killed, 28 rabbits given LR were given a bolus of 2 ml/kg MSD76 IV. Following CT, rabbits were frozen, sliced, and photographed. Abscess volumes were calculated by digitizing the photographs of the anatomic sections and the CT images. MSD76 enhanced the liver by 105 Hounsfield units (HU) more than the liquefied abscess center. The abscess wall enhanced to the same degree as liver, resulting in nonvisualization of three of six abscesses less than 3 mm in size, and a 30% underestimation of true abscess volume.(ABSTRACT TRUNCATED AT 250 WORDS)