Chest radiographic and CT evaluation of lung abnormalities in pediatric patients with laryngeal cleft.

BACKGROUND: The purpose of this study was to (1) evaluate chest radiography (CR) and computed tomography (CT) findings in pediatric patients with laryngoscopically confirmed laryngeal cleft and (2) determine whether CT provided additional information over CR in evaluating lung abnormalities in pediatric patients with laryngeal cleft. METHODS: Two pediatric radiologists performed a retrospective review of CRs and CTs in pediatric patients with laryngoscopically confirmed laryngeal cleft from January, 2002 to January, 2010. Lungs were evaluated for pattern (airspace or interstitial), distribution (upper, middle, or lower lung zones), and extent (<25% or >25%) of abnormalities on CRs and CTs. In patients who had both CR and CT, CT findings were compared with concurrent CRs to determine whether CT provided additional information and resulted in alterations in patient management. RESULTS: The final study cohort consisted of 67 pediatric patients (37 males and 30 females; mean age 3.0 years ± 3.5 years; range 25 days to 17.5 years) who had CR. Sixteen (24%) of these 67 patients had both CR and CT. Chest radiographs were abnormal in 47 patients (70%) which included consolidation (n = 35; 74%) and reticular opacities in 12 patients (26%). Lung parenchymal abnormalities were observed in the upper (n = 10; 21%), middle (n = 2; 4%), or lower (n = 35; 75%) lung zones on CR. The extent of lung parenchymal abnormalities was >25% in 30 patients (64%) and <25% in 17 patients (36%). Chest CT examinations were abnormal in all 16 patients (100%) who had available chest CT examinations, which included consolidation (n = 9; 56%) and reticular opacities (n = 7; 44%). Lung parenchymal abnormalities were observed in the upper (n = 2; 12.5%) or lower (n = 14; 87.5%) lung zones on CT. The extent of lung abnormalities was >25% in 10 patients (60%) and <25% in six patients (40%). CT provided major additional findings in 12 patients (75%) and minor findings in four patients (25%). Additionally, CT improved the evaluation of the distribution and extent of lung abnormalities in 11 patients (69%). The additional information provided by CT resulted in alteration of patient management in seven patients (43.8%). CONCLUSIONS: Among pediatric patients with laryngeal cleft, CR and CT often show lung abnormalities such as consolidation and reticular opacities. CT frequently provides additional information, which may change patient management.

Wheeze detection in the pediatric intensive care unit: comparison among physician, nurses, respiratory therapists, and a computerized respiratory sound monitor.

OBJECTIVE: To correlate wheeze detection in the pediatric intensive care unit among staff members (a physician, nurses, and respiratory therapists [RTs]) and digital recordings from a computerized respiratory sound monitor (PulmoTrack). METHODS: We prospectively studied 11 patients in the pediatric intensive care unit. A physician, nurses, and RTs auscultated the patients and recorded their opinions about the presence of wheeze at baseline and then every hour for 6 hours. The clinician auscultated while the PulmoTrack recorded the lung sounds. The data were analyzed by a technician trained in interpretation of acoustic data and by a panel of experts blinded to the source of the recorded data, who scored all tracks for the presence or absence of wheeze. The degree of correlation among the expert panel, the staff, and the PulmoTrack was evaluated with the Kappa coefficient and McNemar's test. The determinations of the expert panel were taken as the true state (accepted standard). RESULTS: The PulmoTrack and expert panel were in agreement on detection of wheeze during inspiration, expiration, and the whole breath cycle; in all cases the Kappa coefficients were 0.54, 0.42, and 0.50 respectively. The PulmoTrack was significantly more sensitive than the physician (P = .002), nurses (P < .001), or RTs (P = .001). However, the specificity of the PulmoTrack was not significantly different from that of the physician, nurses, or RTs. CONCLUSIONS: Between the physician, RTs, and nurses there was agreement about the presence of wheeze in critically ill patients in the pediatric intensive care unit. Compared to the objective acoustic measurements from the PulmoTrack, the intensive care unit staff was similar in their ability to detect the absence of wheeze. The PulmoTrack was better than the staff in detecting wheeze.

Benefit plan design and prescription drug utilization among asthmatics: do patient copayments matter?

The ratio of controller-to-reliever medication use has been proposed as a measure of treatment quality for asthma patients. In this study we examine the effects of plan-level mean out-of-pocket asthma medication patient copayments and other features of benefit plan design on the use of controller medications alone, controller and reliever medications (combination therapy), and reliever medications alone. The 1995--2000 MarketScan claims data were used to construct plan-level out-of-pocket copayment and physician/practice prescriber preference variables for asthma medications. Separate multinomial logit models were estimated for patients in fee-for-service (FFS) and non-FFS plans relating benefit plan design features, physician/practice prescribing preferences, patient demographics, patient comorbidities, and county-level income variables to patient-level asthma treatment patterns. We find that the controller-to-reliever ratio rose steadily over 1995--2000, along with out-of-pocket payments for asthma medications, which rose more for controllers than for relievers. After controlling for other variables, however, plan-level mean out-of-pocket copayments were not found to have a statistically significant influence on patient-level asthma treatment patterns. On the other hand, physician/practice prescribing patterns strongly influenced patient-level treatment patterns. There is no strong statistical evidence that higher levels of out-of-pocket copayments for prescription drugs influence asthma treatment patterns. However, physician/practice prescribing preferences influence patient treatment.

Cystic fibrosis on the Internet: a survey of site adherence to AMA guidelines.

OBJECTIVES: The Internet permits unprecedented and mostly unrestricted access to medical knowledge; however, concerns exist regarding viewer privacy, accountability of authorship, accuracy of information, and patient safety. To address these issues, the American Medical Association (AMA) has developed guidelines concerning web site content and visitor rights. Cystic fibrosis (CF) is the most common genetically inherited lethal disease in North America. Many Internet sites that provide information on CF have been developed, although adherence to validated guidelines for online health information is not required. The purpose of this study was to assess systematically web sites with content pertaining to CF for adherence to the published AMA guidelines. METHODS: The search term "cystic fibrosis" was entered into a commonly used search engine (Google), and the first 100 eligible sites were reviewed. Each site was examined for adherence to the AMA Guidelines for Medical and Health Information Sites on the Internet using a series of adapted questions. There were 15 questions divided into the following main categories: 1) site structure and viewer privacy, 2) author accountability, 3) scientific citation, and 4) patient safety. The number of positives for each question was tabulated. RESULTS: With respect to site structure, fewer than half (45%) of the reviewed sites indicated a date of last revision. Only 11 (11%) carried an explicit privacy policy. A responsible author or group was listed in only 43 (43%) of 100 sites. Presented data regarding CF was supported by references, sources, or expert review in only 38 (38%) of 100 sites. A medical disclaimer noting that information provided does not substitute for evaluation by a health care team was evident in only 37 (37%) sites. CONCLUSIONS: The majority of easily accessible CF informational web sites do not adhere to guidelines published by the AMA. Patients and families who use the Internet as a CF information resource should examine the web sites carefully and be familiar with the guidelines established by the AMA. Personal information is not protected, and few sites provide explicit privacy guarantees. Finally, CF care teams should inquire about Internet use by patients and families and be prepared to discuss findings from the Internet to heighten patient safety and awareness.