Behavioral Interventions to Reduce Infections in Pediatric Long-term Care Facilities: The Keep It Clean for Kids Trial.

Children in pediatric long-term care facilities (pLTCF) represent a highly vulnerable population and infectious outbreaks occur frequently, resulting in significant morbidity, mortality, and resource use. The purpose of this quasi-experimental trial using time series analysis was to assess the impact of a 4-year theoretically based behavioral intervention on infection prevention practices and clinical outcomes in three pLTCF (288 beds) in New York metropolitan area including 720 residents, ages 1 day to 26 years with mean lengths of stay: 7.9-33.6 months. The 5-pronged behavioral intervention included explicit leadership commitment, active staff participation, work flow assessments, training staff in the World Health Organization "'five moments of hand hygiene (HH)," and electronic monitoring and feedback of HH frequency. Major outcomes were HH frequency, rates of infections, number of hospitalizations associated with infections, and outbreaks. Mean infection rates/1000 patient days ranged from 4.1-10.4 pre-intervention and 2.9-10.0 post-intervention. Mean hospitalizations/1000 patient days ranged from 2.3-9.7 before and 6.4-9.8 after intervention. Number of outbreaks/1000 patient days per study site ranged from 9-24 pre- and 9-18 post-intervention (total = 95); number of cases/outbreak ranged from 97-324 (total cases pre-intervention = 591 and post-intervention = 401). Post-intervention, statistically significant increases in HH trends occurred in one of three sites, reductions in infections in two sites, fewer hospitalizations in all sites, and significant but varied changes in the numbers of outbreaks and cases/outbreak. Modest but inconsistent improvements occurred in clinically relevant outcomes. Sustainable improvements in infection prevention in pLTCF will require culture change; increased staff involvement; explicit administrative support; and meaningful, timely behavioral feedback.

Clinical status: a daily forum for resident discussion and staff education.

A forum at which the timely transmission of critical clinical information is coupled with a formal interdisciplinary teaching program has tremendous value in the long-term care setting. We have combined features of morning report used in teaching hospitals with attributes of "stand-up" meetings to fill this need. Each morning we hold Clinical Status, a gathering of representative staff from all neighborhoods (units) at which we discuss problems that have occurred during the previous 24 hours; admissions, discharges, and transitions; Center-wide concerns such as infection control measures; and upcoming events such as celebrations, lectures, and memorials. In addition, short educational presentations are made by staff members at each session. A survey of attendees confirms our impression that Clinical Status is regarded as an informative, stimulating and vital aspect of life at the Center.

Genetic disorders and congenital malformations in pediatric long-term care.

OBJECTIVE: The objective of this study was to gain insight into the contribution of genetic disorders and congenital malformations to residents of a pediatric long-term care and rehabilitation center. DESIGN: Record review. SETTING: The setting was a 136-bed long-term care and rehabilitation center in New York City. PARTICIPANTS: Participants were residents who spent 1 day or longer as in-patients at the center over a 1-year period of time. MEASUREMENTS: Resident diagnoses were categorized as problems with known genetic basis, problems with presumed genetic basis, acquired disorders with genetic predisposition, contiguous gene syndromes, multiple congenital anomalies, prematurity, cerebral palsy, hypoxic ischemic encephalopathy, conditions with unknown etiology, and defined conditions without genetic basis. The percentage of individuals with genetic disorders and/or congenital malformations was determined. RESULTS: Genetic disorders and congenital anomalies were responsible for 50% of overall admissions and 60% of end-of-life care admissions to a pediatric long-term care center. CONCLUSION: An understanding of the contribution of genetic disorders and congenital malformations can assist long-term care administrators as they plan for the needs of their future residents.

Proposed model for interaction between residents and residency training programs, and pharmaceutical industry.

Medical residents in training are as much targets of pharmaceutical-industry marketing as are physicians in practice. This interaction is often subtle and takes the form of sponsorship of meals at academic events, support for conference travel, books, and items such as pens and notepads. Most residency programs direct little time towards training in ethics and the critical analysis of pharmaceutical-industry marketing. We propose a model for the relationship between residents and residency programs, and the pharmaceutical industry that addresses the need for such interaction to be viewed in light of the patient-centered ethic of professional conduct and the ideal of unbiased medical practice. A committee of residents at different levels of training and two staff physicians received the mandate to examine this issue. The committee developed a set of guidelines and a proposed schema for the handling of funds from pharmaceutical companies (still not implemented). Each residency program would develop a common fund for money donated by pharmaceutical companies. This fund would be administered by a committee with defined priorities. The presence of residents on this committee under staff preceptorship would serve as a springboard for education on the subject. Guidelines for acknowledgement of sponsorship, solicitation of funds, gifts for care of patients, ongoing education, and the wider applicability of these proposals were also developed. Residents' interaction with the pharmaceutical industry during training could have lifelong influence on medical practice. We hope that our model will promote critical appraisal of the potential risks and benefits of this interaction.

Clinical features and mental development of a child with a prenatally identified 45,XX,der(5)t(5;18) (p15;q11.2),-18 karyotype.

We present the clinical features and growth and development of a child with a 45,XX,der(5)t(5;18) (p15;q11.2),-18 karyotype. She had microcephaly, prominent, posteriorly rotated ears, short palpebral fissures with an upward slant, a wide nasal bridge, a thin upper lip, and a short neck. In addition, she had complex congenital heart disease. Although there has been delay in growth and development, she has shown progress in both areas.

Body composition measurement: a review of hydrodensitometry, anthropometry, and impedance methods.

Human body composition is an expression of genetic and nutritional factors. It can change as a consequence of exogenous influences such as training, disease, or diet and is therefore of particular interest to nutrition professionals. Two of the main methods of estimating body composition in this review (hydrodensitometry and anthropometry) have been in use for decades, but the third method (bioelectrical impedance) is more recent. The procedure, theoretical basis, assumptions, standard error of estimates, and comparisons with other techniques are presented for each of the three methods. References to general and specific populations are presented that illustrate regression equations for different ages, ethnic groups, and gender. The advantages and disadvantages of the three methods are reviewed with reference made to the alternative compartment models. Other methods (DEXA, infrared interactance) are briefly reviewed.

Quality of life, body composition and muscle strength in adult growth hormone deficiency: the influence of growth hormone replacement therapy for up to 3 years.

OBJECTIVE: Adults with GH deficiency complain frequently of low energy levels, emotional lability and mental fatigue resulting in a low perceived quality of life (QOL). Body composition is altered with increased fat mass and decreased lean body mass and muscle strength is reduced. The aims of this study were to determine the effects of replacement GH treatment on: (a) body composition and muscle strength and (b) QOL, using specifically selected and adapted measures. DESIGN: A 12-month study (double-blind placebo-controlled for the first 6 months and open for the second 6 months) of GH replacement injections (0.125 iu/kg/week for the first month and 0.25 iu/kg/week for the following 5 months of each study period) in GH deficient adults on QOL, body composition and muscle strength. This was followed by an open study of a further 12 months' GH treatment assessing QOL and muscle strength. Finally, QOL was assessed after up to 3 years of GH replacement treatment. PATIENTS: Thirty of the 32 adult patients with GH deficiency enrolled completed the initial 12-month study (10 male, mean age 33.5 years, mean (SD) stimulated serum GH response 3.0 mU/l (2.86)). Nineteen patients then opted to continue GH treatment. Of these, 13 patients were available for assessment after a further 12 months' and 24 months' treatment. MEASUREMENTS: Health-related QOL was assessed using 2 specifically adapted scales for adults with GH deficiency: the Life Fulfillment Scale and the Impact Scale. In addition 4 other self-rating questionnaires were used: Nottingham Health Profile, Hospital Anxiety and Depression Scale, Self Esteem Scale and Mental Fatigue Scale. Body composition was assessed by DEXA and quadriceps muscle strength by measuring maximum voluntary contractions. RESULTS: In the initial 12 months' placebo-controlled study perceived energy levels increased after 6 and 12 months of GH treatment (P < 0.01 compared with baseline) in the patients receiving GH for the full 12-month period. There were no changes in energy levels throughout the study in the group receiving placebo for the first 6 months. Also small improvements in impact scores were found after 6 months of GH treatment (P < 0.05) but this was not sustained at 12 months. In both GH and placebo groups life fulfillment worsened after 6 months, but then improved to baseline values after 12 months. In the patients who persisted with GH replacement, energy levels continued to improve (at 2 years, P < 0.01 compared with baseline) but then fell (at 3 years, P = NS compared with baseline). A similar pattern was observed in emotional reaction scores. However, improvements in self-esteem were maintained (at 3 years, P < 0.05 compared with baseline). Body composition altered favourably over the initial 12-month study period with a significant increase in lean mass and decrease in fat mass in both groups after 6-12 months of GH. There were no changes in muscle strength in either group during the initial 12-month study. However, in the patients who were available for assessment after a further 12 months of GH treatment, muscle strength increased significantly (P < 0.02 compared with baseline). CONCLUSION: GH replacement treatment for 6-12 months leads to significant improvements in body composition (DEXA) but longer-term treatment may be needed to increase muscle strength. Self-esteem scores improve and are maintained after 3 years of treatment. Energy levels and emotional reaction improve during treatment for up to 2 years but decline thereafter.

High-resolution x-ray imaging of extended lasing plasmas.

An x-ray imaging system with a bent focusing crystal was used for time-resolved one-dimensional imaging of a long plasma column of highly ionized aluminum. This scheme uses a focusing geometry with a spherically bent crystal and a slit on the Rowland circle. Alternative schemes of x-ray monochromatic imaging are briefly discussed. The homogeneity of the up to 40-mm-long laser-generated plasma column was studied with a temporal resolution of 100 ps. The potential spatial resolution of the instrument is 90 microm or better. Monochromatic images taken on the resonance He alpha line of Al XII characterize the homogeneity of a plasma generated to study a recombination x-ray laser scheme, giving an amplified spontaneous emission in Al XI.

Child with Sotos phenotype and a 5:15 translocation.

We report on a 4-year-old girl with Sotos phenotype and a de novo balanced translocation between the long arms of chromosome 5 and chromosome 15 [46,XX,t(5,15)(q35;q22)]. We suggest a relationship between genetic material at 5q35 or 15q22 and the expression of an autosomal dominant gene.

Hydrocephalus in an infant with trisomy 22.

We present an infant with true trisomy 22. Mosaicism is ruled out by the finding of a 47,XX, +22 karyotype in all cells analysed originating from two embryonic germ layers. The physical findings are consistent with the previously noted features including developmental delay, ear abnormalities, micrognathia, clefting, and congenital heart disease. The patient is the first described with macrocephaly and hydrocephalus and the second with holoprosencephaly.

Core-resonance capillary-fiber whispering-gallery-mode laser.

We describe the observation of laser emission at wavelengths corresponding to whispering-gallery modes from a highly refractive dye-doped solvent flowing in a normally illuminated silica capillary fiber. The cylindrical whispering-gallery-mode laser described here differs from the well-known spherical droplet laser in that it has an internal refractive index discontinuity. Boundary-value computations are presented that reveal that the feedback responsible for the observed lasing modes is associated with total internal reflection at the liquidsilica interface. No laser peaks are observed when the refractive index of the solvent is less than that of the silica.

Trisomy 18 score: a rapid, reliable diagnostic test for trisomy 18.

We developed a bedside scoring system for diagnosis of trisomy 18 in the immediate neonatal period. Points are assigned for the presence of features known to occur in trisomy 18: five points for the presence of features previously reported in 50% or more of affected infants; three points for features reported to occur in between 10% and 50% of affected individuals; and one point for features known to occur in less than 10% of infants with the disorder. Using the scoring system, we evaluated two cohorts of patients: those in whom a diagnosis of trisomy 18 was previously established (retrospective group) and those in whom the diagnosis was suspected but not yet proved (prospective group). The average score in the retrospective series (n = 25) was 96.7, and no patient scored less than 70. Twenty-two patients were evaluated prospectively; in all cases the presence or absence of trisomy 18 was correctly predicted. The average score in the 11 patients without trisomy 18 was 41.4, and all patients scored 60 or less. In the 11 patients confirmed to have trisomy 18, the average score was 94.3, with a range of 70 to 113. This scoring system is an accurate, reproducible method for predicting trisomy 18 in neonates with multiple congenital malformations.

Further delineation of the McKusick-Kaufman hydrometrocolpos-polydactyly syndrome.

Six cases of the McKusick-Kaufman syndrome (MKS), including two cases that were diagnosed prenatally, were studied. Review of the 54 previously described cases indicates that postaxial polydactyly and hydrometrocolpos in female patients are the hallmark features of this entity. Other manifestations, such as malformations of gastrointestinal, cardiovascular, and ophthalmic structures, occur less consistently. Affected children require careful medical follow-up. Recurrence of hydrometrocolpos following surgical repair may lead to serious sequelae, such as chronic renal failure. We believe that MKS is a distinct panethnic genetic entity, inherited in an autosomal recessive fashion, and that the diagnosis should be made only in female patients with hydrometrocolpos and polydactyly or in male patients with polydactyly who have an affected female relative.

Autosomal recessive inheritance in the Setleis bitemporal 'forceps marks' syndrome.

We present the clinical findings in two children with the Setleis bitemporal "forceps marks" syndrome. The striking features include the following: (1) bitemporal scarring, an anomaly that resembles forceps marks; (2) periorbital puffiness with wrinkling of the skin; (3) abnormalities of the eyebrows; (4) anomalies of the eyelashes; (5) flattening of the nasal bridge with a bulbous nasal tip; (6) increased mobility of the skin, associated with severely redundant facial soft tissue; and (7) normal growth and development. The evidence that suggests that this unusual syndrome is inherited in an autosomal recessive fashion includes the following: (1) seven of the patients have come from the relatively isolated towns of San Sebastian and Aguadilla in Puerto Rico; (2) two sets of affected siblings have been described, and, in both cases, the siblings' parents were normal; and (3) one of the children described herein is the product of a consanguineous mating. Although the pathogenetic mechanism is unknown, Setleis syndrome is clearly inherited as an autosomal recessive trait.