Nebulized budesonide versus oral steroid in severe exacerbations of childhood asthma.

The aim of this study was to assess whether nebulized budesonide may substitute for oral prednisolone in the management of children whose asthma is severe enough to warrant hospital admission, but who have no life threatening features. In a prospective, double-blind, randomized study nebulized budesonide (2 mg 8 hourly) was compared with oral prednisolone (2 mg/kg at entry and again at 24 h) in 46 children admitted to hospital with severe asthma exacerbations. Efficacy variables (including lung function measurements such as the primary outcome variable, Forced Expiratory Volume in 1 second (FEV1) and symptoms) were measured 24 h after treatment initiation. FEV1 improved significantly compared to baseline in patients who received nebulized budesonide compared to the prednislone group. The data show nebulized budesonide to be at least as effective as oral steroid in improving lung function and symptom severity in severe exacerbations of childhood asthma.

Successful pancolonoscopy and ileoscopy in children.

The purpose of this study was to collect prospective data regarding the quality, extent, and duration of pediatric pancolonoscopy performed by pediatric gastroenterology attending physicians and a fellow in training. Over 7 months, data were prospectively collected on 40 colonoscopic procedures. The cecum was reached in 37 cases (92.5%) and the terminal ileum in 35 cases (87.5%). When cases of stricture and equipment failure were excluded, these completion rates were 97 and 95%, respectively. The overall average duration for pancolonoscopy, ileoscopy, multiple biopsies, and polypectomy (where necessary) was 38 min. When attending physicians performed the procedure, the duration was 31 min; the duration was 37 min when the fellow completed the procedure and 45 min when the fellow required the attending physician to complete it. The average time taken to reach the cecum by the attending physician was 19 min (range, 8-32); by the fellow it was 25 min (range, 17-32), and by the combination it was 37 min (range, 11-59). The average time from cecum to terminal ileum was 3 min for all, with ranges of 1-12 min for the attending physician and 1-23 min for the fellow. The fellow initiated 24 procedures, of which the attending physician was required to complete 12, including all five procedures performed in the initial 2 months of the study, 7 of 13 in the next 3 months, and none of the six procedures in the last 2 months. Of the 40 examinations, the colon was normal in five (12.5%), and a specific diagnosis was made in 35.(ABSTRACT TRUNCATED AT 250 WORDS)

Is cow's milk protein intolerance a cause of gastro-oesophageal reflux in infancy?

To test the hypothesis that cow's milk protein intolerance (CMPI) might cause or contribute to gastro-oesophageal reflux (GOR), 10 of 14 infants with abnormal GOR on prolonged oesophageal pH monitoring who had failed to respond to conventional antireflux therapy were placed on a hypo-allergenic diet for 1 month. In no child was there significant improvement in pH monitoring indices, and only two showed any symptomatic improvement. Therefore, in these children, CMPI did not appear to contribute to GOR. It is probable that CMPI is rare as a cause of passive GOR, although our results do not exclude CMPI as a cause of active vomiting.

Daily variations in steady-state plasma concentrations of carbamazepine and its metabolites in epileptic children.

Total plasma carbamazepine, carbamazepine-10,11-epoxide (CBZ-EP) and 10,11-dihydro-10,11-trans-dihydroxy-carbamazepine (CBZ-DIOL) concentrations were measured during a 24h period in 21 patients receiving carbamazepine monotherapy, in equally divided doses, every 12h. Interdose and diurnal variations in plasma concentrations of parent drug and metabolites were assessed. Carbamazepine and both metabolites showed significant differences in mean 4h post-dose plasma concentrations between day and night dosing (p less than 0.001). Significant linear correlations were obtained between carbamazepine dose and plasma concentrations of carbamazepine, CBZ-EP and CBZ-DIOL when sampling times were standardised (p less than 0.01). Comparisons of plasma concentrations of the parent compound with those of its 2 main metabolites revealed significant linear correlations in all cases (p less than 0.01). The effects of daily fluctuations in plasma concentrations of all 3 compounds on their relative concentrations (CBZ-EP:carbamazepine, CBZ-DIOL:carbamazepine and CBZ-DIOL:CBZ-EP) during the 24h period were also determined: the plasma concentration ratios CBZ-EP:carbamazepine and CBZ-DIOL:carbamazepine were significantly related to the dose of carbamazepine at fixed sampling times (p less than 0.05, with 1 exception). The large interdose and diurnal variation in plasma carbamazepine concentrations observed in this study (approximately 40% decrease from peak to trough) has important implications both clinically and in relation to therapeutic drug monitoring.

Factors influencing plasma level/dose ratios of carbamazepine and its major metabolites in epileptic children.

The relationship between daily dose and plasma concentrations of carbamazepine (CBZ), CBZ-10,11-epoxide (CBZ-EP), and 10,11-dihydro-10,11-trans-dihydroxy-CBZ (CBZ-DIOL) was investigated in 21 children aged 7-16 years who received CBZ monotherapy, twice daily in equally divided doses. Significant linear correlations between CBZ dose and plasma levels were obtained for CBZ and its metabolites (p less than 0.01). In addition, the effects of daily dose and patients' age on the plasma level/dose ratios for CBZ, CBZ-EP, and CBZ-DIOL were evaluated. A significant negative correlation was observed between the daily dose of CBZ and the CBZ plasma level/dose ratio (p less than 0.01). By contrast, plasma level/dose ratios for CBZ-EP and CBZ-DIOL were independent of dose (p greater than 0.1). On the basis of these observations, we consider that the decrease in CBZ plasma level/dose ratio with increasing CBZ dose appears to be due to dose-dependent metabolic clearance of CBZ. The influence of age on plasma level/dose ratios for CBZ and its metabolites was not significant (p greater than 0.05). However, there was considerable interdose and diurnal variation in the plasma level/dose ratios, particularly for CBZ (28-41%); this must be taken into account when making dose adjustments based on plasma level/dose ratios.

Growth after gut resection for Crohn's disease.

Seventeen children underwent 19 bowel resections as part of their management of Crohn's disease. Thirteen children had evidence of retardation of linear growth preoperatively, of whom 12 exhibited catch up growth, crossing at least one centile band, after resection. Seven of the 12 showed early signs of puberty at the time of resection and one child was regarded as being fully pubertal. All children were symptomatic before their surgery; at one year 11 were asymptomatic and three others were substantially improved. Surgical resection of localised Crohn's disease, followed by adequate nutritional support has lead to catch up growth and a prolonged symptom free period in most of our patients and this was not limited by their age or stage of puberty.

Breakthrough seizures with generic carbamazepine: a consequence of poorer bioavailability?

The bioavailability of carbamazepine from two products (Ethical Generics and Ciba-Geigy) and their efficacy with regard to seizure control and incidence of side-effects were compared in 23 children with tonic-clonic or complex partial seizures. Mean plasma concentrations of carbamazepine, carbamazepine 10, 11-epoxide and 10,11-dihydro-10, 11-trans-dihydroxy-carbamazepine at comparable sampling times were not significantly different during treatment with the two drug preparations. The incidence of seizures and occurrence of abnormal EEGs were not significantly different during treatment with the two carbamazepine preparations, and, in addition, the overall incidence of side-effects was not significantly different during the two treatment periods. However, neurological side-effects were significantly less during treatment with the Ciba-Geigy product. On the basis of these observations we are confident that the efficacy of these two carbamazepine preparations in children at steady-state is the same.

Collaborative practice: a critical theory perspective.

The purpose of this critical theory study was to investigate the observed failure of nurses and physicians to collaborate, and the underlying meaning behind this failure. Using a phenomenological and participatory approach, 18 family nurse practitioners and physicians in joint practice were interviewed separately and together about their practice relationships. Transcribed interviews and data summaries were returned to the participants for review and validation. Emergent themes were analyzed using the critical theory of Jürgen Habermas. Results demonstrated that distorted communication and nonmeaningful interactions were promoted by both nurses and physicians. Elements identified as contributing to more successful collaborative practices included a willingness to move beyond basic information exchange in nurse/physician interactions, the willingness and ability to challenge distortions and assumptions in the relationship, and a belief system based on critical self-reflection.

Comparison of capillary and arterial blood gas measurements in neonates.

One hundred and fifty eight paired arterial and capillary blood samples were obtained from 41 sick preterm infants in their first week of life and the pH, and PCO2, and PO2 concentrations were measured. Half of the capillary samples were obtained from unwarmed heels and half from heels warmed to 40 degrees C. A potentially significant discrepancy (arbitrarily defined as 0.05 units for pH. 1 kPa for PCO2, and 3 kPa for PO2) was found in 19 (24%) of cases for pH, in 9 (11%) for PCO2 and in 21 (26%) for PO2. Warming the heel produced no significant improvement in results. We conclude that capillary blood provides satisfactory measurements of pH and PCO2 for all but the most critical purposes, but that the usefulness of capillary PO2 estimations is limited to the exclusion of hypoxia.

Sources of error in neonatal blood sampling.

Significant underestimation of blood electrolyte concentrations may occur if less than 1 ml of blood is withdrawn from an indwelling arterial line before taking the sample for analysis. Compared with arterial samples capillary samples give significant overestimations of potassium concentration and carbon dioxide tension, and significant underestimation of oxygen tension.

Collaborative practice: the nurse practitioner's role in its success or failure.

This study critically analyzes the underlying values, beliefs and behaviors of 18 family nurse practitioners and physicians who identified themselves as being in a joint practice relationship. Participants in the study were interviewed separately and in pairs around issues related to their reasons for joint practice, their interactional patterns, and how these patterns could be different. Transcribed interviews and data summaries for each practice were returned to the participants for review, discussion and validation. Results of the study suggested that the language, values and behaviors of the nurses continued to support, to varying degrees, the authoritarian and dominant position of the physician. In addition, nurses tended to demonstrate distorted communication and non-meaningful interactions. The possibility for nurses to create conditions in the practice relationship oriented toward mutual understanding and effective collaboration was clearly apparent in a few of these practices. Steps essential in achieving these conditions include the following: 1) self reflection; 2) clarification of goals; 3) examination of interactional patterns; 4) analysis of the level of commitment to mutual understanding; 5) willingness to risk calling issues into question; 6) conscious commitment to maintaining this level of communication over time; and 7) facilitating the physician partner's commitment to these goals.

A collaborative intercampus model for graduate studies in primary care nursing.

A feasibility study was conducted to determine the appropriateness of developing an intercampus curriculum for graduate studies in nursing with collaboration between a School of Medicine at one campus and a School of Nursing at another. Methods of data collection included interviews with a broad scope of administrators, faculty and students, synthesis of survey data and other documentation, and a consultation visit by a representative of the United States national accreditation body for nursing. From these data, an advisory committee of faculty administrators from each campus jointly determined the most appropriate criteria upon which to base an intercampus program. A curriculum preparing students in the specialties of either midwifery or family practice was created. The advantages and disadvantages of this collaborative effort are described, along with conclusions regarding factors influencing the effectiveness of the program.

Establishment of an intermediate care ward for babies and mothers.

This paper describes one year's experience with the running of a special postnatal ward area, established so that babies who needed more treatment and monitoring than is generally undertaken on postnatal wards but who did not need the facilities of the neonatal unit could be kept by their mother's bedside. This 'intermediate care ward' admitted 297 babies with their mothers during its first year of operation. We estimate that the opening of the ward led to a 20% reduction in admissions to the neonatal unit, without disadvantage to any baby. The indications for admission are outlined and the reactions of patients and staff to the innovation discussed.

Health management. Levels of intervention for a coexistence model.

Conceptualizing health and illness as separate, but coexisting, interacting phenomena provides the basis for delineating levels of intervention and for incorporating intervention strategies for both health and illness. This approach provides a model which directs clinical practice toward an emphasis on both health care and illness care. Nursing providers need to take the lead in recognizing that an equal if not greater emphasis on the health continuum will assist in the delivery of the full range of care necessary to meet both the health and illness care needs of society.

The use of contingent-interrupted music in the treatment of disruptive bus-riding behavior.

The present study evaluated the efficacy of using contingent-interrupted music in treating the disruptive bus-riding behavior of an 8-year-old profoundly retarded female. Music was played during each bus ride as long as the subject was sitting appropriately, and interrupted contingent upon each response defined as disruptive bus riding, during an ABCDCDCDA design. A significant reduction in disruptive bus riding occurred with each introduction of contingent-interrupted music. The treatment procedure described in this report was easy to administer, produced rapid treatment gains, and showed virtually no regression during an 8-week follow-up period.