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Biomedical subjects

K J Kemper

Publications and source records attributed to K J Kemper.

13 recordsLinked to original sources
PubMed1992

The case against screening urinalyses for asymptomatic bacteriuria in children.

Screening children for asymptomatic bacteriuria to prevent pyelonephritis and renal scarring is widely recommended, but its cost-effectiveness has not been established. We reviewed published studies to determine the costs and benefits of screening toilet-trained, asymptomatic children for bacteriuria. Given the sensitivity and specificity of current screening methods (approximately 80% each) and the prevalence of bacteriuria in asymptomatic children (approximately 1% in girls and 0.03% in boys), screening 100,000 children would result in 19,897 (20%) false-positive tests; initial screening and two urine cultures to confirm the diagnosis of asymptomatic bacteriuria would miss 28% of 515 children with true bacteriuria, and cost nearly $2.9 million. There is no evidence that detection and treatment of children with asymptomatic bacteriuria prevents subsequent pyelonephritis or renal scarring. Screening for bacteriuria in asymptomatic children is costly, fails to prevent pyelonephritis or renal scarring, and should be discontinued as a part of routine well-child care.

Bacteriuria↗
PubMed1992

Screening for maternal depression in pediatric clinics.

OBJECTIVE: The purpose of this study was to assess the frequency of and risk factors for depressive disorders among mothers of young children and to compare the eight-item RAND screening instrument for depressive disorders with an easily scored three-item version of the test. DESIGN: A cross-sectional survey. SETTING: Five pediatric clinics in the Seattle-Tacoma, Washington area, two private practices, two university-affiliated teaching clinics, and the Madigan Army Medical Center pediatric clinic. PARTICIPANTS: Convenience sample of 667 English-speaking mothers who completed the depression items on an anonymous self-administered questionnaire on family health. INTERVENTIONS: None. MEASUREMENTS AND RESULTS: The results of women surveyed showed that 19% were positive for depression on the RAND instrument. Women whose survey results were positive were younger (28.2 vs 30.3 years of age), had less education (12.9 vs 14.4 years), and had lower monthly incomes ($1803 vs $2923) than those who results were not positive. Positive scores were more common among women surveyed in teaching clinics (20%) and military clinics (24%) than among women surveyed in private practices (12%), among single vs married mothers (32% vs 15%), among nonwhites vs whites (29% vs 16%), and among those with positive screening test results for drugs compared with those with negative screening test results (45% vs 17%) (P less than .01 for all comparisons). Compared with the eight-item instrument, the three-item version had a sensitivity of 100%, a specificity of 88%, and a positive predictive value of 66%. CONCLUSIONS: Depression is common among mothers of young children. The three-item version compares favorably with the eight-item RAND screening instrument for depressive disorders.

Adult↗
PubMed1992

Interobserver variability in assessing pediatric postextubation stridor.

The reliability of parameters used to assess pediatric postextubation upper respiratory distress is unknown. We prospectively studied the interobserver reliability of six parameters commonly used to assess respiratory distress in children. Eligible patients were less than 15 years old and hospitalized for traumatic injuries at Harborview Medical Center between March and September 1989. At extubation, patients were examined independently by a physician, a nurse, and a respiratory therapist, each of whom evaluated respiratory rate (RR), stridor, air movement, flaring/retractions (F/R), level of consciousness (LOC), and oxygen saturation (O2 sat). Reliability was measured by percentage agreement and weighted kappa (Kw). The 25 children (27 extubations) had a median age of 7 years, and eight of the 27 required treatment for upper airway obstruction. Percentage agreement ranged from 82% (for air movement) to 96% (for O2 sat). Weighted kappas were excellent for RR and F/R (Kw greater than .6); moderate for LOC, stridor, and O2 sat (0.4 less than Kw less than .06); and poor for air movement (Kw less than .4). Further improvements in interobserver agreement are required to provide more consistent upper airway management in critically ill children.

Academic Medical Centers↗
PubMed1992

Self-administered questionnaire for structured psychosocial screening in pediatrics.

Screening for psychosocial risk factors has been limited by lack of a structured approach. The purpose of this study was to assess the utility of a self-administered questionnaire compared with routine history as recorded in the medical record in screening for risk factors for dysfunctional parenting in an urban pediatric clinic. English-speaking parents were offered questionnaires in the waiting room. In addition to routine demographic and medical questions, the questionnaires contained standard screening instruments for substance abuse, depression, self-esteem, and social support, as well as questions about domestic violence, homelessness, and parental history of abuse as a child. Medical records were reviewed separately. Of the 114 mothers who returned questionnaires, the response rate for sensitive questions such as income was greater than or equal to 85%. Compared with the medical record, the questionnaire identified significantly more mothers with possible substance abuse, depression, low self-esteem, and/or history of abuse as a child (P less than .01 for each). Compared with what is usually recorded in the medical record, self-administered questionnaires yield substantial additional information regarding psychosocial risk factors for dysfunctional parenting. Such questionnaires should be considered for routine psychosocial screening in clinics serving high-risk populations.

Child↗
PubMed1991

Predictors of postextubation stridor in pediatric trauma patients.

OBJECTIVE: To determine which factors are the best predictors of postextubation stridor in pediatric trauma patients. DESIGN: Prospective cohort study. SETTING: The Burn and Trauma ICUs at Harborview Medical Center from March to September 1989. PATIENTS: Children were eligible for the study if they were less than 15 yr old, were intubated for greater than 12 hr, and did not have underlying cardiopulmonary disease. The study included 25 patients with 30 extubations. RISK FACTORS ASSESSED: Age, type of injury (burn vs. trauma), location of intubation ("field" vs. hospital), endotracheal tube size, length of intubation, and presence of an airleak around the tube at the time of extubation at 30 cm H2O pressure. MAIN OUTCOME MEASURE: Moderate to severe postextubation stridor requiring treatment with racemic epinephrine, helium-oxygen, reintubation, or tracheostomy. RESULTS: Treatment for postextubation stridor was required after 11 (37%) of 30 extubations, with five reintubations and one tracheostomy. The best predictor of postextubation stridor was absence of an airleak at the time of extubation (sensitivity 100%, positive predictive value 79%, p less than .001), followed by type of injury (facial burn vs. all others; sensitivity 64%, positive predictive value 88%, p less than .001). After controlling for these two factors, no other factor studied was a significant predictor of postextubation stridor. CONCLUSION: In pediatric trauma patients, mechanism of injury (facial burn vs. other) and absence of an airleak at the time of extubation are the strongest factors predicting postextubation stridor. Patients with one or both risk factors require special attention to airway management.

Adolescent↗
PubMed1991

Helium-oxygen mixture in the treatment of postextubation stridor in pediatric trauma patients.

OBJECTIVE: To assess the effectiveness of a helium-oxygen mixture in reducing post-extubation stridor in children hospitalized for burns or trauma. DESIGN: Randomized, controlled crossover trial. SETTING: Harborview Medical Center's Burn and Trauma ICUs from March to September 1989. PATIENTS: Children less than 15 yr old who were electively extubated and had symptoms of postextubation stridor, but required less than or equal to 35% oxygen. INTERVENTION: Each treatment (helium-oxygen and oxygen-supplemented room air) was given in random order for 15 min after extubation. MEASUREMENTS: Respiratory distress was assessed by a physician blinded to treatment order using a standard stridor score and clinical judgment. RESULTS: There were 13 children with 15 extubations; seven (47%) of 15 patients required subsequent treatment with racemic epinephrine or reintubation. Stridor scores were lower with helium-oxygen than with oxygen-supplemented room air (2.8 vs. 3.7, p less than .005), and helium-oxygen was preferred in eight of nine trials in which one treatment was clearly favored by the physician. CONCLUSION: Because helium-oxygen therapy can reduce stridor scores and is clinically preferred by physicians caring for stridorous children, it may be a useful adjunctive therapy in pediatric trauma patients with postextubation stridor.

Adolescent↗
PubMed1990

Persistent perceptions of vulnerability following neonatal jaundice.

Treatments for neonatal jaundice are generally considered both safe and effective. We hypothesized that such treatments would be associated with symptoms of the vulnerable child syndrome, persisting up to 6 months. Mothers of otherwise healthy infants who had jaundice and demographically similar infants without jaundice born at Yale-New Haven (Conn) Hospital were surveyed and compared 6 months after discharge from the hospital. By 6 months, the infants with jaundice had significantly more feeding difficulties, eg, they were less likely to be breast-feeding. Unexpectedly, the mothers of infants with jaundice switched from being less likely to leave their infants with someone else at 1 month to leaving the infants significantly more than mothers of infants in the comparison group. Although the mothers of infants in the comparison group reported a similar number of infant health problems, the mothers of infants with jaundice were more likely to judge the problems as serious and to have taken the infant to an emergency department. The benefits of treating jaundice in otherwise healthy infants should be weighted against the risks of developing the vulnerable child syndrome.

Adult↗
PubMed1989

The reliability and validity of the pediatric appropriateness evaluation protocol.

Researchers at Yale-New Haven Hospital (New Haven, Connecticut) tested the reliability and validity of the Pediatric Appropriateness Evaluation Protocol (PAEP) through a comparison of inter-rater agreement between experienced pediatricians and less experienced clinicians. The PAEP is a diagnosis-independent instrument with 26 criteria in three categories used to assess appropriate hospital use in pediatrics. Pediatrician raters, using clinical judgment alone, and clinicians (fellows in pediatrics and nurse practitioners), using both clinical judgment and the PAEP, reviewed a sample of 47 days and judged which inpatient days were medically appropriate. A day was judged appropriate if any of the 26 criteria were fulfilled for that day and inappropriate if none of the criteria was fulfilled. The PAEP was found to be a reliable and valid instrument with a 93% sensitivity and a 78% specificity for detecting medically inappropriate days.

Evaluation Studies as Topic↗
PubMed1988

Medically inappropriate hospital use in a pediatric population.

To assess the extent of inappropriate hospital use in pediatric inpatients, I modified the Appropriateness Evaluation Protocol (AEP)--developed to assess inappropriate hospital use in adults--to apply to children and used it to evaluate pediatric inpatients retrospectively for every 10th day, from July 1982 to July 1983, at the University of Wisconsin Hospital. Of 1098 patient-days evaluated, 21.4 percent were judged to represent inappropriate hospital use on the basis of the protocol's criteria. The rate of inappropriate use varied according to admitting specialty, ranging from 7 of 70 days (10 percent) for pulmonary medicine to 43 of 61 days (70 percent) for neurology (P less than 0.005). There was a tendency toward lower rates of inappropriate use in uninsured patients (6 of 44 days [14 percent] vs. 226 of 1038 days [22 percent] in patients with Medicaid or private insurance, P = 0.13), and rates were lower in younger children (74 of 432 days [17 percent] in children less than or equal to 5 years of age vs. 162 of 656 days [25 percent] in children greater than 5 years of age, P less than 0.005). There was no variation according to sex, day of the week, or month. Contrary to expectations, inappropriate use decreased with increased lengths of stay (for stays of 1 day, 8 of 13 days were inappropriate [61 percent]; for stays of 2 to 6 days, 118 of 410 days were inappropriate [29 percent]; for 7 to 13 days, 58 of 291 [20 percent]; and for greater than or equal to 14 days, 51 of 362 [14 percent], P less than 0.001). I conclude that there is a substantial rate of inappropriate hospital use in pediatrics and that such use is more likely during short admissions than during long ones. Cost-containment efforts directed at limiting the length of hospitalization may therefore not reduce inappropriate hospital use in this population.

Adolescent↗
PubMedDate not supplied

Treatment of postextubation stridor in a pediatric patient with burns: the role of heliox.

Stridor is a common problem in patients with burns after extubation, especially in children and in those with facial burns or airway injuries. The usual treatments for severe respiratory distress, such as reintubation and tracheotomy, carry substantial risks for patients. We report our successful treatment of severe postextubation stridor in a 7-year-old patient with burns with the administration of heliox in addition to more traditional therapies, review the literature about the use of heliox in postextubation stridor, and suggest cases in which its use may prevent the need for more hazardous interventions.

Burns↗