Showing papers by "Hospital for Sick Children published in 1999"

Cost of Chickenpox in Canada: Part I. Cost of Uncomplicated Cases

Abstract: Objective. The purpose of this study was to assess the direct medical costs and productivity losses associated with uncomplicated chickenpox (no hospitalization) in Canada. Methods. A total of 179 otherwise healthy 1- to 9-year-old children with active chickenpox were recruited from schools, day care centers, and physician offices in 5 provinces. Direct medical (physician contacts, medication, and diagnostic tests) and nonmedical (personal expenses including child care) resources expended during the illness were determined by caregiver interview. Productivity losses attributable to the disease were determined by assessing caregiver time lost from work and daily activities. Unit costs for all resources were obtained from sources in 2 provinces, and per-patient treatment costs were determined from the patient, Ministry of Health, and societal perspectives. Results. From a societal perspective, the per-case cost for children from 1 to 4 years of age and from 5 to 9 years of age was $370.2 and $236.5, respectively. Direct medical costs accounted for 10% of the total costs in both groups. The largest cost driver in patient care was caregiver productivity losses, which amounted to $316.5 in the younger age group and to $182.7 in the older age group. Based on an estimated yearly incidence of 344 656 cases of uncomplicated chickenpox in Canada, the total annual societal burden of the disease can be estimated at $109.2 million, with a cost to the Ministry of Health of $11.2 million. Conclusion. Chickenpox is one of the last common childhood diseases prevalent in Canada, and the uncomplicated disease, despite its rather benign course, imparts a large annual economic burden.

Reading after closed head injury in childhood: Effects on accuracy, fluency, and comprehension.

Abstract: Two studies of reading decoding, reading fluency, and reading comprehension after childhood head injury are reported. Study 1 tested whether age at head injury and the type of contusional brain damage were related to reading outcomes. Fifty-five children with head injuries were tested on measures of word decoding accuracy and reading comprehension. Children who sustained head injuries in the preschool years before basic word decoding skills are acquired or in the early primary grades when decoding skills are being taught, and children with bilateral or left-sided contusions were most at risk for difficulties in acquiring basic word decoding and reading comprehension skills. In particular, children injured before 61/2 years of age were most at risk for difficulties in acquiring reading decoding skills in comparison to children injured after this age. Study 2 tested whether deficits in processing speed after head injury are also found in reading. Forty-three head-injured children were matched with controls on a pair-by-pair basis for age, grade, and word decoding accuracy. The children with head injuries were slower at naming words, particularly those with less common orthographic patterns, although the groups did not differ on speeded naming of pronounceable nonwords. Reading fluency in the head-injured group was related to reading comprehension, suggesting that slow word-level processing has negative consequences for text comprehension in these individuals. The results are discussed with respect to how head injuries affect the development of skills yet to be acquired and the further acquisition of those skills that are in a rapid phase of development at time of injury. The results are also discussed with reference to models of how head injury affects speeded processing.

Cost of Chickenpox in Canada: Part II. Cost of Complicated Cases and Total Economic Impact

Abstract: Objective. Primarily, to determine the direct medical costs and productivity losses associated with complicated chickenpox (hospitalized cases) and, secondarily, to quantify the overall economic burden of chickenpox in Canada. Methods. Direct medical resource consumption patterns were determined by chart review of 160 otherwise healthy children and 40 children with leukemia hospitalized for chickenpox. Children were selected from the database of the Immunization Monitoring Program Active (IMPACT), a network of 11 tertiary-care hospitals in Canada that collected information at the time of hospitalization from January 1991 to March 1996. An additional 26 healthy children hospitalized were recruited prospectively by IMPACT. Productivity losses (time lost from work and daily activities) were assessed by caregiver interviews. Treatment costs were determined from the patient, Ministry of Health, and societal perspectives. Results. The average societal per case cost for complicated chickenpox in healthy children was $7060 and $8398, respectively, from the retrospective and prospective assessments. For children with leukemia, the direct medical cost was estimated at $7228. These costs were combined with a cost established previously for uncomplicated chickenpox. The estimated yearly overall economic impact of chickenpox in Canada was $122.4 million, with $24.0 million attributable to Ministry of Health costs, assuming an estimated yearly incidence of 346 527 cases and a 0.54% rate of hospitalization for healthy children. Conclusions. Direct medical costs are the major cost driver in the care of complicated chickenpox. However, in the context of the overall economic burden of the disease, uncomplicated chickenpox is the major cost driver, contributing 89% to the total cost.

A randomized trial of 72- versus 24-hour intravenous tubing set changes in newborns receiving lipid therapy.

Abstract: Objective:To compare the microbial contamination rate of infusate in the intravenous tubing of newborns receiving lipid therapy, replacing the intravenous delivery system at 72-hour versus 24-hour intervals.Design:Infants requiring intravenous lipid therapy were randomly assigned to have intravenous sets changed on a 72- or a 24-hour schedule, in a 3:1 ratio, in order to compare the infusate contamination rates in an equivalent number of tubing sets.Setting:A 35-bed, teaching, referral, neonatal intensive-care unit (NICU).Participants:All neonates admitted to the NICU for whom intravenous lipid was ordered.Methods:Patients were randomized in pharmacy, on receipt of the order for intravenous lipid therapy, to either 72- or 24-hour administration set changes, and followed until 1 week after discontinuation of lipids or discharge from the NICU. Microbial contamination of the infusate was assessed in both groups at the time of administration set changes. Contamination rates were analyzed separately for the lipid and amino acid-glucose tubing sets. Patient charts were reviewed for clinical and epidemiological data, including birth weight, gestational age, gender, age at start of lipid therapy, duration of parenteral nutrition, and type of intravenous access.Results:During the study period, 1,101 and 1,112 sets were sampled in the 72- and 24-hour groups, respectively. Microbial contamination rates were higher in die 72-hour group than the 24-hour group for lipid infusions (39/1,101 [3.54%] vs 15/1,112 [1.35%]; P=.001) and for amino acid infusions (12/1,093 [1.10%] vs 4/1,103 [0.36%]; P=.076). Logistic regression analysis controlling for birth weight, gestational age, and type of venous access showed that only the tubing change interval was significanfly associated with lipid set contaminations (odds ratio, 2.69; P=.0013). The rate of blood cultures ordered was higher in die 72-versus the 24-hour group (6.11 vs 4.99 per 100 patient days of total parenteral nutrition; P=.017), and a higher proportion of infants randomized to the 72-hour group died (8% vs 4%; P=.05), although the excess deaths could not clearly be attributed to bacteremia.Conclusion:Microbial contamination of infusion sets is significantiy more frequent with 72- than witii 24-hour set changes in neonates receiving lipid solutions. This may be associated with an increased mortality rate.

Preconception counseling and women's compliance with folic acid supplementation.

Abstract: QUESTION: I am counseling patients to take folic acid when they plan pregnancy and during early pregnancy. Is there any proof that counseling really causes women to comply? ANSWER: A recent Motherisk study showed that counseling women who were planning pregnancy about folic acid use is very effective: 71% of those counseled took folic acid, compared with only 17% of those who were not counseled.

Characterization of platelet glycoproteins and platelet/endothelial cell antibodies in patients with thrombotic thrombocytopenic purpura.

Abstract: Platelets and sera from 12 patients with thrombotic thrombocytopenic purpura (TTP) and 12 healthy normal control subjects were examined. As determined by quantitative flow cytometry, prior to plasma exchange therapy platelet surface glycoprotein (GP) Ib levels were similar in TTP patients and normal controls (mean 20 188 and 20 226 molecules/platelet, respectively). Platelets from patients with TTP did, however, have significantly reduced levels of GPIIb/IIIa prior to plasmapheresis (mean 36 348 v 52 505 molecules/platelet in controls; P = 0.0004) and of GPIV (mean 13 321 v 26 212 molecules/platelet in controls; P = 0.0002). An increase in activated platelets, as determined by CD62 expression, was observed in 82% of patients. Increased platelet-associated immunoglobulins and/or complement was also seen in approximately 60% of the patients. In general, with return of platelet counts to normal levels following seven plasmaphereses, the above abnormalities were reversed, although often not to normal levels. Western blot analysis indicated the presence of antibodies reactive to platelet GPIV (88 kD) in 70% of pretreatment sera from patients with TTP; a similar band was observed in 80% of patient sera against microvascular endothelial cells. Immunofluorescence microscopic examination indicated the presence of antibody in pretreatment sera from patients with TTP to microvascular (73%) and large vessel (36%) endothelial cells. As measured by an indirect flow cytometric assay, pretreatment sera from 55% of patients with TTP were reactive with large vessel endothelial cells and 100% reacted with microvascular endothelial cells; reactivity was significantly greater against the microvascular endothelial cells (P = 0.0048) and was reduced following plasma exchange therapy. These results indicate abnormalities in platelet glycoprotein expression in TTP and suggest that anti-platelet and anti-endothelial cell antibodies play a role in the thrombocytopenia and vasculitis characteristic of this disorder.

Continuing drug therapy while breastfeeding. Part 1. Common misconceptions of patients.

Abstract: QUESTION: Some of my patients who need specific drugs during the postpartum period are hesitant to breastfeed even when I tell them that, according to available evidence, these drugs are safe. Am I right about this and how should I advise my patients? ANSWER: Recent studies reveal that women receiving chronic therapy tend to initiate breastfeeding much less often than mothers in the general population and, if they do initiate, discontinue it much earlier. While reassuring counseling is generally correlated with continuation of breastfeeding, women receiving chronic medications still discontinue breastfeeding earlier. Stressing the clear benefits of breastfeeding and the lack of apparent risk of drugs shown to be safe should be coupled with repeated reassurance to mothers during close follow up of their babies.

Localized morphea in children.

Abstract: We are following 60 patients with morphea and/or linear scleroderma at the Hospital for Sick Children, Toronto Lesions may vary in depth from epidermal changes resembling lichen sclerosis, to superficial and deep dermal changes The subcutaneous tissue, bone and muscle may be involved There is no good clinical marker of the disease Because of the variation in the time to cure, it is difficult to evaluate treatment regimens We are currently using methotrexate weekly either orally or subcutaneously and monthly pulsed steroids for three months

Pharmacological Treatment of Attention-Deficit/HyperactivityDisorder

Abstract: A vast body of research and clinical experience about the pharmacological treatment of Attention-Deficit/Hyperactivity Disorder (ADHD) has been gathered over several decades. In this chapter’s review of this literature, we particularly emphasize the role and effects of psychostimulants, the most commonly prescribed medications for children with ADHD and the most extensively studied. We examine the current role of medication in the treatment of ADHD, summarize the contemporary concepts of the neurochemical rationale for the effects of the various drugs used to treat ADHD, and comment on the benefits and limitations of each class of medication. Although we emphasize the clinical implications of existing knowledge about drug effects, we do not provide a guide to clinical practice for the treatment of children with ADHD.

Fetal Echocardiographic Predictors of Morbidity and Mortality in Congenital Diaphragmatic Hernia

Abstract: Fetal Echocardiographic Predictors of Morbidity and Mortality in Congenital Diaphragmatic Hernia

Tetralogy of Fallot with non-confluent pulmonary arteries and aortopulmonary septal defect.

Abstract: Aortopulmonary septal defect and tetralogy of Fallot is a rare combination. We report a case of tetralogy of Fallot, non-confluent pulmonary arteries with the left arising from the arterial duct, and a large aortopulmonary septal defect diagnosed by echocardiogram and confirmed by cardiac catheterization.

Erythema infectiosum (Fifth disease) and pregnancy.

Abstract: QUESTION: One of my patients is currently 14 weeks pregnant. She is a teacher in grade 1, and there is an epidemic of Fifth disease in the school where she teaches. Can this disease affect her pregnancy and how should I care for her? ANSWER: Erythema infectiosum (Fifth disease) is usually a benign disease for children and mothers, but might have serious consequences for a fetus due to hemolytic anemia, although the risk is very low. You should evaluate the mother's immune status. If she is already immune (IgG positive), the risks are nil. If she is not immune (although the risk of the fetus's being affected is very low), fetal surveillance by repeated ultrasonographic examination and immune status reevaluation has been recommended. If a fetus is found to be affected, intrauterine evaluation and treatment are available at tertiary care centres.

Exposure to organic solvents. Does it adversely affect pregnancy

Abstract: QUESTION: One of my patients is a laboratory technician who routinely handles organic solvents. She has just learned that she is pregnant, and she depends very much on this job because her husband is unemployed. What is the risk to her unborn baby? ANSWER: Available epidemiologic data indicate your patient's fetus might be at increased risk for malformations. We recommend that she minimize her occupational exposure to organic solvents by routinely using ventilation systems and protective equipment. This is most important during the first trimester of pregnancy.

Dextromethorphan. Extrapolation of findings from reproductive studies in animals to humans.

Abstract: QUESTION: One of my patients, who is now 8 weeks pregnant, just read in the newspaper that dextromethorphan (DM), an antitussive found in a variety of cough medicines, caused birth defects in chicken embryos. The author of the study stated that even one dose could be dangerous and that he would never allow his wife to use this drug if she were pregnant. My patient was understandably very concerned because last week she was suffering from a nasty cough and had been advised by her pharmacist to use a cough mixture containing DM, which she subsequently took for several days. ANSWER: You may reassure your patient that she did not put her baby at risk by using this substance. Dextromethorphan has been on the market for many years and has never been implicated as a human teratogen. Furthermore, chick embryos are not a good model for predicting teratogenic potential in humans and, consequently, were abandoned as such more than 30 years ago.

Does the "sanctity of human life" doctrine sanctify humanness, or life?

Abstract: No single principle is more critical to our ethical stance than the one asserting the sanctity of human life. In debates ranging from the care of anencephalic infants to the maintenance of fragile seniors, the question is, Where are the boundaries of sanctified human life? The generally accepted assumption is that a once firm set of principles and definitions is now eroding in the face of “new realities”—a generation's stunning scientific advance in medicine and medical technology. “There is no doubt,” Joam Graf Haber writes, for example, in a recent issue of Cambridge Quarterly, “that the miracles of medical technology have brought up ethical issues not contemplated by us until the very recent past.”

Neonatal lupus erythematosus.

Abstract: Neonatal lupus is categorized by typical clinical features and the presence of maternal auto-antibodies. Mothers are uncommonly affected with clinical disease. The major clinical manifestations in neonates are cardiac, dermatological and hepatic, with rare instances of haemolytic anaemia and thrombocytopenia. The major morbidity and mortality result from complete congenital heart block. Dermatological manifestations occur mainly over the face and present with plaques of erythema with central atrophy, a mid-facial erythema, atrophy around the eyes and a telangiectatic variety. The long term outcome is usually excellent.

β-Helical propensity of Ala-based peptides in organic solvents

Abstract: The α-helix is one of the main building blocks for protein structures. Previous studies indicate that individual amino acids have distinct helical preferences that influence the stabilities of protein secondary structures and folding in aqueous environments. However, in membrane environments, which provides a very different solvation matrix from water, the rules governing protein folding will tend to differ from those directing folding in the aqueous milieu. Yet, only modest progress has been made towards understanding the conformational preferences for the individual amino acids in membrane environments, largely because of the scarcity of high resolution structural data on membrane proteins. In the present work, a series of Ala-based model peptides are employed to address some aspects of this long-standing ‘puzzle’. The organic solvent 90% isopropanol, with dielectric constant between pure water and the hydrocarbon interior of biological membranes, was used to mimic the nonpolar environment of membranes.