Inpatient burden of childhood functional GI disorders in the USA: an analysis of national trends in the USA from 1997 to 2009.

BACKGROUND: Functional gastrointestinal disorders (FGIDs) are among the most common outpatient diagnoses in pediatric primary care and gastroenterology. There is limited data on the inpatient burden of childhood FGIDs in the USA. The aim of this study was to evaluate the inpatient admission rate, length of stay (LoS), and associated costs related to FGIDs from 1997 to 2009. METHODS: We analyzed the Kids' Inpatient Sample Database (KID) for all subjects in which constipation (ICD-9 codes: 564.0-564.09), abdominal pain (ICD-9 codes: 789.0-789.09), irritable bowel syndrome (IBS) (ICD-9 code: 564.1), abdominal migraine (ICD-9 code: 346.80 and 346.81) dyspepsia (ICD-9 code: 536.8), or fecal incontinence (ICD-codes: 787.6-787.63) was the primary discharge diagnosis from 1997 to 2009. The KID is the largest publicly available all-payer inpatient database in the USA, containing data from 2 to 3 million pediatric hospital stays yearly. KEY RESULTS: From 1997 to 2009, the number of discharges with a FGID primary diagnosis increased slightly from 6,348,537 to 6,393,803. The total mean cost per discharge increased significantly from $6115 to $18,058 despite the LoS remaining relatively stable. Constipation and abdominal pain were the most common FGID discharge diagnoses. Abdominal pain and abdominal migraine discharges were most frequent in the 10-14 year age group. Constipation and fecal incontinence discharges were most frequent in the 5-9 year age group. IBS discharge was most common for the 15-17 year age group. CONCLUSIONS & INFERENCES: Hospitalizations and associated costs in childhood FGIDs have increased in number and cost in the USA from 1997 to 2009. Further studies to determine optimal methods to avoid unnecessary hospitalizations and potentially harmful diagnostic testing are indicated.

Adenomas with high-grade dysplasia and early adenocarcinoma are more likely to be sessile in the proximal colon.

AIM: Size and the sessile morphology of an adenoma may explain why colonoscopy is less effective in preventing proximal colonic cancer than distal cancers. We wanted to determine if advanced polypoid neoplasms (APNs, i.e. adenoma with high-grade dysplasia or early adenocarcinoma) are more likely to be sessile and/or smaller in the proximal colon. METHOD: We searched our institution's pathology database from 2004 to 2012 and identified patients with APNs. Polyps were categorized by size, morphology and location in the colon. Average polyp size and morphology were determined for each location. RESULTS: During the study period, 564 patients with APNs were identified. Of these, adenocarcinoma was noted in 21.6% and high-grade dysplasia in 78.4%. The average patient age was 64.4 years and 54.9% were men. The proportion of APNs that were ≤ 5 mm was 1.7%, ≤ 10 mm 19.3% and ≤ 15 mm 39%. APNs in the proximal colon were larger than those in the distal colon, but the difference was not statistically significant (27 vs 24 mm; P = 0.06). Eighty-three per cent of APNs in the proximal colon were sessile vs 57% in the distal colon (P = 0.001). APNs in the proximal colon were almost four times more likely to be sessile than in the distal colon (OR = 3.7). A similar association was noted for polyps ≤ 20 mm or polyps with high-grade dysplasia. CONCLUSION: APNs in the proximal colon were almost four-times more likely to be sessile than those in the distal colon. No difference in the size of polyps was noted.

In-patient discharge rates for the irritable bowel syndrome - an analysis of national trends in the United States from 1997 to 2010.

BACKGROUND: Irritable bowel syndrome (IBS) is one of the most common out-patient diagnoses in primary care and gastroenterology. There are limited data on the rate and costs associated with in-patient discharges for IBS. AIM: To estimate the incidence and costs of hospital discharges for IBS in the United States. METHODS: We analysed the National Inpatient Sample database for all subjects in which IBS (ICD-9 code: 564.1) was the principal discharge diagnosis from 1997 to 2010. The National Inpatient Sample contains data from approximately 8 million hospital stays each year. Our findings reflected patient and hospital characteristics like geographical region and bed size. RESULTS: In 1997, there were 11 433 patients with a principal discharge diagnosis of IBS as compared to 12 842 in 2010 (P > 0.9, GoF test). The mean length of stay for IBS also remained the same between 1997 and 2010 at 3.7 ± 0.1 days. However, during this period, the mean hospital charges per hospitalization increased by 207.8% from $6873 ± 198 in 1997 to $21 153 ± 598 in 2010 (P < 0.01). The aggregate charges (i.e., 'national bill') for IBS increased by 245.5% from $78 524 129 ± 3 781 316 in 1997 to $271 311 405 ± 14 023 289 in 2010 (P < 0.01). CONCLUSIONS: The number of in-patient discharges and length of stay for IBS have remained relatively stable between 1997 and 2010, whereas the cost associated with these discharges has increased significantly. In-patient costs associated with IBS contribute significantly to the total healthcare bill. Further research on the cost-effectiveness of diagnostic procedures and therapies in IBS is required.

Contact investigation for cases of pulmonary Mycobacterium bovis.

SETTING: A local tuberculosis control program in San Diego County, California. OBJECTIVE: To determine the yield of contact investigations of pulmonary Mycobacterium bovis cases. DESIGN: Retrospective review of medical records comparing tuberculin skin test (TST) conversion rates found in contact investigations of pulmonary M. bovis cases to conversion rates found in contact investigations of pulmonary M. tuberculosis cases. RESULTS: For the years 1994-2001, we identified 77 contacts of pulmonary M. bovis cases and 469 contacts of M. tuberculosis cases that met the study criteria. TST conversion rates were not significantly different based on species of the source case (13% for M. bovis, 15% for M. tuberculosis, P = 0.20). This finding was also observed when the results were stratified by presence of a cavity on chest X-ray, history of cough at diagnosis and human immunodeficiency virus (HIV) status of the source case. CONCLUSION: These results suggest that contact investigations for pulmonary M. bovis cases should be conducted in the same manner as those conducted for pulmonary M. tuberculosis cases.

Children's behaviour and the urban environment: an ecological analysis.

This research examines the spatial distribution and ecological correlates of problem behaviour amongst children living in the most highly urbanised portion of Greater Victoria, British Columbia, Canada. Rates of problem behaviour within the sample differ substantially, at the census tract level, with respect to the mean rate calculated for the study area as a whole. While the degree of spatial concentration varies between behaviour types, each exhibits a similar overall trend, with the highest rates in the western and/or central portions of the study area, and the lowest rates around its northern and eastern periphery. Bivariate correlation analyses reveal significant ecological relationships between rates of problem behaviour and census measures of aggregate socio-economic status. The degree to which the urban ecology of the study area is related to census tract rates of problem behaviour is dependent upon the nature of the behaviour being considered. Results of contextual analyses using five ecological variables and their family-level equivalents suggest that, in some cases, census tract characteristics may have an independent impact upon behavioural status.

Treatment of anxiety disorders in late life.

OBJECTIVE: To provide a current review and synthesis of the present state of knowledge of anxiety disorders and symptoms in the elderly. METHODS: Current research derived from a MEDLINE search and references in key textbook articles and other papers were reviewed. These data were combined with the clinical empirical knowledge and experience of the authors. RESULTS: Anxiety disorders and symptoms are a common presenting problem in the elderly. Current knowledge and research findings are limited. Extrapolation from adult studies are of use, but important limitations are evident because of the nature, uniqueness, and complexity of the geriatric psychiatry patient. Comorbidity, especially with depression, medical conditions, drugs, and dementia, remains an important concept in assessment and approach to management of anxiety in the older person. Comprehensive assessment of anxiety symptoms requires consideration of physical, intellectual, environmental, and social determinants. Major anxiety disorders, as defined by DSM-IV, and anxiety symptoms are significant problems in the older adult population and are responsible for significant morbidity and cost to the health care network. CONCLUSIONS: Anxiety disorders and symptoms in old age, although common, have received little research focus to date. A comprehensive, careful approach by the clinician to assessment and management is required because anxiety is often a comorbid condition in the elderly. Effective treatments are available and should be applied in a flexible, integrated, and specific manner.

Urban ecological structure and perceived child and adolescent psychological disorder.

This research examined the distribution and ecological correlates of referrals of children and adolescents to the Regional Children's Centre, a psychological assessment and treatment centre located in Windsor, Ontario, Canada. Referral data were collected by the Regional Children's Centre for the study period April 1992 through March 1994. The ecological structure of the study area was derived using principal components analysis of a set of socio-economic indicator variables from the 1991 Census of Canada and a cluster analysis of component scores. Referral rates were calculated for each ecological area for two referral subgroups; modi/conduct/stress-related concerns and neurophysiologically based concerns. The distribution of referrals was tested using the Poisson probability test. This test revealed that, for both subgroups analysed, the distribution of referrals in the study area was non-random. Stepwise multiple regression revealed a significant ecological relationship between the mood/conduct/stress-related concerns referral rate and the ecological structure of the study area. No such relationship was found, however, when examining referrals for neurophysiologically based concerns.

Central line associated bacteremia in the pediatric patient.

PURPOSE: To define the per-day risk of central line associated bacteremia in an infant-toddler population and to describe risk factors associated with the development of central line bacteremia. METHOD: The Central Line Data Tool collected information on 102 central venous catheters from 73 patients ranging in age from 1 day to 29 months. Each line was in place for 3 days or longer. FINDINGS: There were 17 documented catheter-related infections during the 1-year study period (7.7 infections per 1,000 catheter days). Factors significantly associated with central line bactermia included: PAS infusion, catheter type and site, medication administration, blood withdrawal, and accidental line disruption. CONCLUSIONS: Use of central lines for multiple purposes should be minimized.

Intraorganizational influence in the health care setting: a study of strategies preferred by head nurses and infection control practitioners.

BACKGROUND: The purpose of this study was to examine influencing strategy preferences among head nurses (HNs) in the operating room, HNs in critical care and ICPs. METHODS: A 21-item questionnaire on influencing strategy was used to identify 8 dimensions of influence: assertiveness, sanctions, ingratiation, rationality, bargaining, upward appeal, manipulation, and coalitions. The questionnaires were randomly distributed by regional coordinators in nine geographic regions throughout the United States to an operating room HN, a critical care HN, and an ICP at each of 12 hospitals (six with < 250 beds, six with > 250 beds). Two hundred ninety-seven respondents (92%) participated in the study. RESULTS: Although both HNs and ICPs rated rationality (logic, information, and appeal to intelligence) highest as the preferred approach to influence behavior, ICPs rated this dimension significantly higher than both operating room HNs and critical care HNs (p < 0.001). The least preferred strategy among all three groups was sanction (threatening job security). Critical care HNs rated manipulation (threatening to stop working with the other person) significantly higher than did both operating room HNs (p = 0.04) and ICPs (p = 0.01). Age was found to be a factor in the preference for sanctions as an influencing strategy, regardless of specialty: respondents younger than 40 years preferred sanctions less as a means to change behavior than did those older than 40 years (p < 0.01). CONCLUSION: These findings have implications for effective intraorganizational influence in health care settings.

A pilot study of sphincter-sparing management of adenocarcinoma of the rectum.

After analysis of 26 prospectively accrued patients with distal rectal adenocarcinomas who underwent sphincter preservation treatment, we have concluded that tumors that invade only the submucosa can safely be treated with surgery alone and that tumors that invade the muscularis or further can be safely treated with surgery combined with chemoradiotherapy. None of the patients had either local or distant recurrence, with a median follow-up of 21 months. All patients have been fully continent. The results, although preliminary, imply that resection of distal rectal adenocarcinoma with sphincter preservation, and adjuvant therapy when appropriate, have achieved local and distant control equal to the conventional Miles' abdominoperineal resection, but without the need for a permanent colostomy.

A review of antiseptics. Cleansing agents.

1. The cells of the stratum corneum are rough, jagged, and contain myriad niches in which bacteria dwell. The complex structure of the stratum corneum limits complete access of any chemical; an antiseptic agent must have contact to kill bacteria. 2. Shaving hair on the skin, long considered essential prior to surgery, has been shown to sabotage the effectiveness of the preoperative skin preparation. 3. Experimental evidence over a long period has documented that no other agent can achieve as rapid and large a reduction in skin flora as alcohol. 4. The preoperative hand scrub calls not only for removal of dirt, grease, and pathogens from the surface of the hands, but also a maximum reduction of the resident flora.

Comparison of nasal brush and nasopharyngeal aspirate techniques in obtaining specimens for detection of respiratory syncytial viral antigen by immunofluorescence.

Diagnosis of respiratory syncytial virus by antigen detection is dependent on obtaining adequate respiratory epithelial cells. Two specimen collection methods, nasopharyngeal aspiration (NPA) and nasal brushing (NB), were compared. Thirty-two pediatric patients with presumed viral pneumonia or bronchiolitis (34 episodes) had both NPA and NB performed. Of 34 specimens 15 were culture-positive for respiratory syncytial virus. Of these 12 NPA samples and 10 NB samples had viral inclusions by immunofluorescent antibody staining (IFA). Of culture-negative samples, 1 of 17 NB was positive by IFA. One specimen obtained by NB had too few cells to read by the IFA method. Sensitivity and specificity were 80 and 100% for NPA and 67 and 94% for NB. Total respiratory cells and IFA-positive cells (classified as few, moderate, or many) were greater with NPA; however, NB was also an effective procedure and was better tolerated by children, less expensive and easier to perform.

Effect of preoperative shampoos with chlorhexidine or iodophor on emergence of resident scalp flora in neurosurgery.

Wound contamination with endogenous bacterial scalp flora plays an important role in the pathogenesis of postoperative neurosurgical infections. To assess the effect of preoperative antiseptic shampoos on the emergence of resident scalp flora during surgery and subsequent wound contamination, we randomized 151 neurosurgical procedures into four study groups: group A--preoperative shampoos with chlorhexidine, surgical scalp preparation with chlorhexidine; group B--no shampoos, surgical preparation with chlorhexidine; group C--shampoos with iodophor, surgical preparation with iodophor; group D--no shampoos, surgical preparation with iodophor. Quantitative cultures of the scalp were obtained preoperatively and at the end of surgery, and qualitative wound cultures were taken prior to wound closure. Group A had the lowest concentration of bacteria on the scalp both preoperatively and postoperatively (median range = 30 [0-5.7 x 10(5)] and 0 [0-2.5 x 10(3)] respectively). Group A also had significantly fewer positive postoperative scalp cultures (29%) than groups B (51%), C (58%), and D (53%) (P less than 0.05), as well as fewer positive wound cultures (20% v 25%, 42%, and 30% respectively). A density of bacteria on the scalp of greater than 10(2)/4cm2 best predicted the presence of bacteria in the wound. Repeated preoperative shampoos with chlorhexidine reduce intraoperative emergence of resident skin flora and subsequent contamination of the wound.

Effect of preoperative shampoos with chlorhexidine or iodophor on emergence of resident scalp flora in neurosurgery.

Wound contamination with endogenous bacterial scalp flora plays an important role in the pathogenesis of postoperative neurosurgical infections. To assess the effect of preoperative antiseptic shampoos on the emergence of resident scalp flora during surgery and subsequent wound contamination, we randomized 151 neurosurgical procedures into four study groups: group A-preoperative shampoos with chlorhexidine, surgical scalp preparation with chlorhexidine; group B-no shampoos, surgical preparation with chlorhexidine; group C-shampoos with iodophor, surgical preparation with iodophor; group D-no shampoos, surgical preparation with iodophor. Quantitative cultures of the scalp were obtained preoperatively and at the end of surgery, and qualitative wound cultures were taken prior to wound closure. Group A had the lowest concentration of bacteria on the scalp both preoperatively and postoperatively (median range = 30 [0-5.7 x 10(5)] and 0 [0-2.5 x 10(3)] respectively). Group A also had significantly fewer positive postoperative scalp cultures (29%) than groups B (51%), C (58%), and D (53%) (P<0.05), as well as fewer positive wound cultures (20% v 25%, 42%, and 30% respectively). A density of bacteria on the scalp of < 10(2)/4 cm(2) best predicted the presence of bacteria in the wound. Repeated preoperative shampoos with chlorhexidine reduce intraoperative emergence of resident skin flora and subsequent contamination of the wound.

Coagulase-negative staphylococcal bacteremia in the changing neonatal intensive care unit population. Is there an epidemic?

A fivefold increase in the number of cases of nosocomial coagulase-negative staphylococcal bacteremia was investigated in a neonatal intensive care unit between 1975 and 1982. This apparent outbreak was not the result of increased isolation of coagulase-negative staphylococci from blood cultures nor an increased frequency with which blood cultures were obtained. Rather, it was attributable to a dramatic increase in the overall probability that a positive blood culture would be interpreted as "bacteremia" as opposed to a contaminant by both physicians and infection control staff. Specifically, there had been a 62.3% increase in neonatal intensive care unit bed use by very-low-birth-weight (less than 1000-g) infants between 1975 and 1982, and in both years, positive blood cultures were 3.8 times as likely to be perceived as clinically significant if obtained from such tiny infants. The growing number of very-low-birth-weight babies occupying neonatal intensive care unit beds, coupled with the observation that blood cultures positive for coagulase-negative staphylococci are almost four times as likely to be perceived as clinically significant if obtained from extremely premature infants, may account for the reported increase in nosocomial coagulase-negative staphylococcal bacteremia.

Prevention of nosocomial respiratory syncytial virus infections through compliance with glove and gown isolation precautions.

To determine whether increased compliance with a policy of glove and gown isolation precautions could reduce the high rate of nosocomial respiratory syncytial virus (RSV) infection on an infant and toddler ward, we conducted a longitudinal intervention trial during three RSV seasons, from 1982 to 1985, with an intervention to increase compliance introduced midway through the second season. The risk of acquiring RSV infection in the hospital was adjusted for the intensity of nosocomial exposure to the virus by assigning each study week to one of five strata, defined by the proportion of hospital days on which virus was shed by children on the ward. Overall, 37 patients acquired nosocomial RSV infections during 7547 days at risk. The adjusted relative risk, comparing the infection rate in the period before the intervention (when compliance with isolation precautions was noted in only 38.5 percent of the observed patient contacts) with the infection rate in the postintervention period (when compliance more than doubled) was 2.9 (95 percent confidence interval, 1.5 to 5.7). Rates of nosocomial RSV infection increased linearly with increasing levels of exposure to patients shedding virus, but the rise in the infection rate with increasing exposure was less than one fourth as great (P less than 0.001) in the period after the intervention as it was before. We conclude that glove and gown precautions can substantially reduce the nosocomial transmission of RSV, particularly with increasing exposure to patients shedding the virus.

Horizontal nonparenteral spread of hepatitis B among children.

Two families with an unusually high incidence of hepatitis B infection (15 of 21 persons) were investigated over an 18-month period. Serologic evidence of past or present infection--hepatitis B surface antigen (HBsAg), antibody to hepatitis B surface antigen (anti-HBs), or antibody to hepatitis B core antigen (anti-HBc)--was found in 11 of the 12 members of one family, four of whom were chronic HBsAg carriers, and in four of nine members of a contact family. Anti-HBc was the only serologic marker of infection in five persons. Histocompatibility leukocyte antigen (HLA) typing failed to show an association between carriage of HBsAg and specific HLA markers. Chewing gum was a potential vehicle as HBsAg was detected in gum samples from three of four children who were chronic HBsAg carriers. Horizontal, nonparenteral transmission of hepatitis B virus probably accounted for the clustering of infection in these families, especially via the exchange among children of objects contaminated with oral secretions.

Haemophilus influenzae type B meningitis: a contagious disease of children.

The families of 126 consecutive patients with Haemophilus influenzae type B meningitis were surveyed for secondary invasive H influenzae disease among household contacts. A total of 120 of the families were contacted. In six cases no contact was possible and the medical record was reviewed. Some 555 household contacts were found; 31% (171) were under 5 years of age. A secondary case was defined as a household contact with H influenzae type B isolated from blood or cerebrospinal fluid more than 24 hours, but less than 30 days, after admission to hospital of the index case. Four secondary cases were identified, all in children aged under 5 years. The secondary attack rate in children under 5 years or less in the month after exposure to an index case was thus 2.3%, 800 times the endemic attack rate for H influenzae meningitis. This is a conservative estimate since five additional contact cases were documented, but not included in the secondary attack rate. Young contacts of a child with H influenzae meningitis are thus at significant risk of life-threatening secondary disease.