Biomedical subjects
Publications and source records attributed to Loren G Yamamoto.
Millions of pediatric patients require some level of emergency care annually, and significant barriers limit access to appropriate services for large numbers of children. The American Academy of Pediatrics has a strong commitment to identifying barriers to access to emergency care, working to surmount these obstacles, and encouraging, through education and system changes, improved levels of emergency care available to all children.
Many published reports state that the type of resuscitation fluid to be used for volume expansion should be "isotonic crystalloid" or "isotonic fluid". Generally, this terminology refers to normal saline (NS) and lactated Ringer's (LR) solution. This terminology is suboptimal technically since not all "isotonic" crystalloids are sufficient volume expanders. A total of 48 reference books from the areas of general pediatrics, pediatric emergency medicine, emergency medicine, pediatric critical care, pediatric surgery, general surgery, internal medicine, family medicine, adult critical care, obstetrics and gynecology, endocrinology, and life support course manuals were reviewed. The description of fluids for hypovolemic shock, trauma, and diabetic ketoacidosis resuscitation was accurate in 46% of the time.
BACKGROUND: The oxygen saturation (OSAT) of wheezing children presenting to an emergency department has been shown to be a predictor for hospitalization. The purpose of this study is to determine if hospitalization predictive power can be increased by further stratifying this by the step severity categories (based on chronic symptoms). METHODS: Data were collected prospectively at 6 centers over a 22-month period on 1219 pediatric patients. Asthma step severity categorization was determined by chronic symptom history. Presenting ED OSAT values, extensive clinical histories (obtained in the ED and during several telephone follow-up calls by study personnel), treatments, and disposition were recorded for each study subject. RESULTS: The overall hospitalization rate was 15%. Hospitalization rates in severity step categories 1, 2, 3, and 4 were 13%, 16%, 13%, and 22% (P = .008), respectively. Hospitalization rates by presenting OSATs were 98% or higher (6%), 95% to 97% (12%), 93% to 94% (28%), 90% to 92% (45%), 85% to 89% (65%), and 80% to 84% (100%). From 95% to 100% OSAT values, hospitalization rates are similar between the severity groups. In the 93% to 94% OSAT group, the hospitalization rate is 43% in step category 4 patients, compared with 27%, 24%, and 13% for step categories 1, 2, and 3, respectively, but this difference was not statistically significant. At presenting OSAT values of 90% and below, the hospitalization rates are higher but did not differ significantly between the severity step groups. No recognizable trend was present to suggest that the hospitalization predictive value is increased by adding the step severity categories. CONCLUSIONS: The presenting OSAT is the dominant initial predictor of hospitalization. The step severity categories do not appear to provide substantial additional predictive value for hospitalization.
TARGET AUDIENCE: Physicians, nurse practitioners and physician assistants who care for infants and children in the emergency department or in other ambulatory and acute care settings. In particular, physicians with administrative responsibilities will find this information useful. OBJECTIVES: 1. Describe the purpose and scope of an electronic medical record. 2. Point out the unique demands that the emergency department places upon an EMR. 3. List the advantages and disadvantages of computerized charting.
OBJECTIVES: The Hawaii Child Asthma Research to Elevate Standards (CARES) Program implemented an emergency department (ED)-based education and management program to facilitate National Asthma Education and Prevention Program (NAEPP) guideline understanding among asthmatic children and their families, ED staff, and health care providers. METHODS: The multipronged approach used: (1) 2-phased prospective tracking system of ED asthma patients; (2) ED-based educational intervention for patients/families; and (3) asthma education for ED staff and community-based health care providers. Data were collected across 4 EDs during phase I (October 8, 2002, to October 1, 2003) and phase II (October 1, 2003, to July 8, 2004). Follow-up data were collected by telephone 3 weeks (phase I), and 3 weeks and 3 months (phase II) after the ED encounter. The patient/family intervention was delivered throughout phase II. During phase I, ED and community-based health care professionals developed strategies for building an integrated asthma care system. ED staff training was delivered before phase II. Continuing medical education for health care providers was delivered before and during the first month of phase II. RESULTS: Tracking data on 706 phase I and 353 phase II patient encounters revealed that the majority of patients with persistent asthma did not use long-term controller medications and did not possess a written asthma action plan. From preintervention to postintervention, the number of patients possessing a written asthma action plan increased from 48 to 322. Of 186 persistent asthmatics, 34 were using controller medications daily, 34 as needed, and 118 not at all. Daily use increased to 80 3 weeks postintervention and to 68 3 months postintervention. CONCLUSION: An ED-based childhood asthma tracking system can serve as a basis for designing and implementing an ED-based educational intervention. ED staff, primary care providers, and others can work together to promote asthma care.
OBJECTIVE: Childhood and adolescent obesity is an increasing public health problem. Fast food consumption has been linked to obesity. The purpose of this study is to determine adolescent calorie and fat consumption patterns at different types of restaurants. METHOD: Study subjects (104 adolescents) were asked to order a dinner meal from 10 restaurant menus with an estimate of how much they would actually consume. A paired T-test was used to compare the calories and fat values for each restaurant vs. McDonald's. RESULTS: Mean calories/fat (g) ordered at each restaurant were: California Pizza Kitchen (CPK).: 1284/70, Chili's (Ch). 1333/62, Denny's (Den): 1226/61, McDonald's (MD): 1016/45, Outback Steakhouse (OS): 1656/93, Panda Express (PE): 873/29, Red Lobster (RL): 1016/49, Stuart Anderson's (SA). 1058/52, Taco Bell (TB): 800/34, Wendy's (Wen): 879/32. Calorie/fat content of the ordered items were significantly higher at CPK, Ch, Den, and OS compared to McDonald's. RL and SA were not significantly different from MD. Calorie/fat content of the ordered items were significantly lower at PE, TB and Wen compared with McDonald's. CONCLUSION: More calories/fat were ordered at many sit down restaurants compared to McDonald's. The lowest calories/fat were ordered at other fast food restaurants (Taco Bell, Wendy's and Panda Express).
100 teens ranked pain experienced for their most recent "shot"on three different scales: casual 0-10 scale (mean 3.3), faces scale (mean 2.8), and 10 cm visual analog scale (mean 2.4). All pain scores showed wide variation (poor validity). Pain severity values were not equivalent across the different pain scales with the casual 10 scale most likely to overestimate pain values.
Heptavalent conjugate pneumococcal vaccine (PCV7) is now routinely administered to infants. Medical records from a pediatric outpatient clinic were used to identify two study groups: 1) those born between January 1995-May 1997(controls), 2) those born between April 2000--May 2001 (PCV7 group). The PCV7 group showed a lower incidence of otitis media episodes, clinic visits for fever and respiratory symptoms, antibiotic prescriptions, ceftriaxone use, and hospitalizations (singled sided probabilities).
BACKGROUND: Dental fracture is a complication of laryngoscopy and endotracheal intubation. PURPOSE: The purpose of this study is to compare the potential fracture rates in dental models using metal laryngoscope blades with those using plastic laryngoscope blades. METHODS: Size 3 Macintosh plastic and metal laryngoscope blades were applied against 4 different dental model materials at varying torques to determine when the dental model material would fracture. RESULTS: The plastic blade did not fracture any of the dental model materials. The metal blade fractured the glass dental model material even at the lowest torque setting. At a moderate torque setting, the plastic blade showed evidence of structural failure, whereas the metal blade did not fail at any torque setting. Fracture of wooden dowel and ceramic teeth model materials occurred with the metal blade but only at torque settings higher than what the plastic blade could achieve. CONCLUSION: Based on the dental fracture models studied, plastic laryngoscope blades have a lower potential for dental fracture compared with metal blades. Plastic laryngoscope blades would be best suited for trainees performing routine intubations under direct supervision. Metal blades would be more advantageous in difficult intubations preferably done by experienced intubators.
OBJECTIVE: To determine the compliance rate in filling outpatient medication prescriptions written upon discharge from the emergency department (ED). METHODS: Emergency department records of children during a 3-month period were examined along with pharmacy claim data obtained in cooperation with the largest insurance carrier in the community (private and Medicaid). Pharmacy claim data were used to validate the prescription pick-up date. RESULTS: Overall, 65% of high-urgency prescriptions were filled. The prescription pick-up rate in the 0-to 3-year age group (75%) was significantly higher than in the rest of the cohort (55%) ( P < .001). Children with private insurance were more likely to fill their prescriptions (68%) compared to children with Medicaid insurance (57%) ( P = .03). CONCLUSION: This study demonstrates that filling a prescription after discharge from an ED represents a substantial barrier to medication compliance.
BACKGROUND: There are several types of emergent zipper release methods described. The standard method can be difficult. The purpose of this study is to determine if an alternate method of zipper release can be easier to accomplish. METHODS: Subjects were provided with zippers and were taught 2 methods of emergent zipper release using a standard method (cutting the median bar of the actuator) and an alternate method (cutting the closed teeth of the zipper). The elapsed times to successful zipper release for both methods were measured. RESULTS: Mean zipper release times were faster for the alternate method (10.5 seconds) compared with the standard method (75.8 seconds) ( P < .001). CONCLUSION: The alternate method of zipper release is faster and easier than the standard method of zipper release; however, the optimal procedure is also dependent on the location of the entrapped tissue relative to the zipper actuator and the type of zipper.
INTRODUCTION: Appropriate lumbar puncture (LP) needle length selection may be more difficult for less experienced practitioners or for patients who are of unusually large or small body habitus. The purpose of this study is to determine if there is a relationship between body height and weight, and the percutaneous depth to the spinal canal, which can more reliably assist in selecting an LP needle length. METHODS: This is a retrospective cohort study of patients who received an abdominal computed tomographic scan (for any reason) from July 1999 to December 2000. Lumbar puncture depth was measured on the computed tomographic scan and was used to derive a formula. RESULTS: The final data pool consisted of 175 patients, aged 25 days to 80 years, with height of 48 to 181.5 cm, weight of 3.0 to 127.3 kg, and body mass index of 11.7 to 49.7 kg/m2. Using this data set, the formula for predicting the required LP depth is (weight in kilograms, height in centimeters): LP depth (cm) = 1 + 17 x weight/height. Using linear regression comparing the skin to mid-spinal canal depth measurements with the calculated LP depths, R2 was 0.81 (P < .001). This formula selected a needle that was too short in 6% (less than that of 4 other previously published LP needle length selection methods) and a needle that was too long in 31%. CONCLUSION: Compared with other formulas, this formula might be a more reliable predictor for estimating the required LP needle length, but this must be validated by further studies. It should be noted that none of the formulas were perfect.
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PURPOSE: To determine whether adolescents will modify their ordering behavior if calorie and fat nutrition information is posted on the restaurant menu. METHODS: Adolescent volunteers (aged 11 to 18 years) were asked to order a dinner of their choice from three different restaurant menus (McDonald's, Panda Express, and Denny's) and then from a second set of modified menus with calorie and fat content information posted next to each menu item. Total reported consumed calories, fat, and the price of the meal ordered were calculated for each meal. RESULTS: For the first 106 adolescents enrolled, 75 did not change any of their orders after being shown the calorie and fat content information. For the 31 who did change some of their orders, 43 meals resulted in decreased calories and 11 meals resulted in increased calories (20 resulted in a more expensive meal, 23 resulted in a less expensive meal and 11 resulted in no change in the cost of the meal; average change 0.027 dollar increase). Of the 27 who rated themselves as too fat or slightly overweight, only 9 (33%) changed their orders. CONCLUSIONS: The provision of calorie and fat content information on the menus did not modify the food ordering behavior for the majority of adolescents. However, the provision of the nutrition information should still be encouraged because it resulted in some calorie/fat reduction by some of the adolescents and it did not adversely affect the restaurants' revenue.
The diagnosis of acute otitis media is based on several clinical factors. One of these factors is the color of the tympanic membrane (TM). Crying can cause flushing and hyperemia of the face. The purpose of this study is to determine whether crying affects the color of tympanic membranes. Infants and toddlers (age 30 months or less) evaluated in an outpatient clinic or primary care pediatrician's office for routine well-baby checks who received at least 2 parenteral immunizations were enrolled on a convenience basis. Ill children were excluded. The initial physician assessed crying and TM color/visibility. Following immunizations, a second physician assessed crying and the TM color/visibility. Color differences were stratified by the degree of crying. One hundred twenty-one study subjects received 2-5 parenteral immunizations. TM colors were most often in the pink range or less. Only 2 TMs were assessed as light red and none were assessed as red. Twenty-eight percent of the TMs with greater crying on the second exam were noted to be redder on the second exam compared to the first exam versus 11% for the comparison group (p=0.0007); 19% of the TMs with greater crying on the second exam were noted to be redder by 2 or more increment levels compared to the first exam versus 5% for the comparison group (p=0.0004); 31% of the TMs with greater crying on the second exam at the 3+ and 4+ level were noted to be redder on the second exam compared to the first exam versus 14% for the comparison group (p=0.003). Our data indicate that, in some instances, crying can result in an increase in pinkness of the TM. Crying in well children does not result in a red tympanic membrane.
PURPOSE: To describe the incidence of erythromycin-induced resistance to clindamycin in a sample of Staphylococcus aureus isolates. METHODS: 100 erythromycin-resistant and clindamycin-sensitive S. aureus were collected as a convenience sample from February to August 2003. Inducible clindamycin resistance was identified using the D-zone disc method. RESULTS: Of the 100 Staphylococcus aureus isolates, 64 were methicillin sensitive (MSSA) and 36 were methicillin resistant (MRSA). Of the 64 MSSA isolates, 22 (34%) had inducible resistance. Of the 36 MRSA isolates, 4 (11%) had inducible resistance. Overall, 26% of these clindamycin sensitive S. aureus isolates, exhibited inducible resistance to clindamycin. CONCLUSIONS: In this sample, MSSA isolates were almost three times more likely to have inducible MLS resistance compared to MRSA isolates. Inducible resistance may compromise the efficacy of clindamycin. The frequency of inducible resistance in this series of "clindamycin sensitive" S. aureus isolates is 26%. It is likely that the true percentage of clindamycin resistance is being underestimated since testing for inducible resistance is not routinely performed.
OBJECTIVES: To determine normal oxygen saturation (OSAT) values in infants and children measured by pulse oximetry METHODS: Infants and children admitted to a children's hospital for elective surgery from 11/20/2000 to 3/30/2002 underwent surgical clearance screens consisting of illness symptoms, vital signs and OSAT in room air Based on the presence of respiratory infection (RI) symptoms, a "normal" patient was defined as one without respiratory symptoms and who was not scheduled for surgery involving the airway pulmonary or cardiovascular systems (APC). RESULTS: Of the 3600 forms collected, 2069 were completely filled out and for elective surgery. For all age groups combined, the percent of patients undergoing APC surgery or with RI symptoms for each OSAT were as follows (OSAT: %patients APC/RI): 100%: 13%, 99%-99.5%: 15%, 98%-98.5%: 14%, 97%-97.5%: 18%, 96%-96.5%: 38%, 95%-95.5%: 29%, and <95%: 0%. CONCLUSIONS: Although OSAT of 95% and 96% are adequate (i.e., not requiring acute oxygen therapy), these values are associated with higher rates of APC/RI involvement and thus should be considered potentially abnormal. OSAT of 97% is on the border of normal. Normal OSATs can occur with APC/RI conditions, but an OSAT less than 97% is associated with a higher risk of an APC/RI condition.
OBJECTIVE: The purpose of this report is to describe the editing and publication of a textbook to increase the opportunity for faculty to contribute textbook chapters, using the internet WWW to facilitate the editing process. METHODOLOGY: An outline of 22 sections containing 214 chapters, was developed. Each section was assigned to an editor Editors recruited authors for each of their section chapters. Chapters were submitted to the editors, then a chief editor completed the editing for the chapter. RESULTS: Chapters that were completed early were posted on the WWW which permitted additional review by the authors facilitating communication with the editors. The additional lead time on the WWW permitted indexing and identification by internet search engines (e.g., Google), so that by the time the textbook was completed, most major search engines had already identified the on-line textbook. Page/type-setting was streamlined by the electronic transfer of the equivalent on-line chapter files to the publisher. 41 chapters were contributed by 18 senior faculty, 51 chapters were contributed by 29 assistant professors, 46 chapters were contributed by 23 non-faculty community physicians, 38 chapters were contributed by 27 residents, and 40 chapters were contributed by 37 medical students. CONCLUSION: A textbook project such as this provides faculty with the opportunity to contribute to the medical literature enhancing their professional development. The WWW provides a new forum for publishing a textbook. It also provides a new communication option between editors and authors to better coordinate the content and editorial style of the chapters.