The shadow uniform resource locator: standardizing citations of electronically published materials.

Citation of scientific materials published on the Internet is often cumbersome because of unwieldy uniform resource locators (URLs). The authors describe a format for URLs that simplifies citation of scholarly materials. Its use depends on a simple HTML device, the "refresh page." Uniform citation would follow this format: [Author I. Title of article. http:// domain/year/month-day(e#).html]. The HTML code for such a page is: (HTML) (head) (meta HTTP-EQUIV="Refresh" CONTENT="0; URL= http://Actual-URL/ for-article/ referred-to/ incitation.html") (/head) (/HTML). The code instructs the browser to suppress the content of the refresh page and bring up the title page of the cited article instead. Citations would be succinct and predictable. An electronic journal would not need to alter its existing file hierarchy but would need to establish a distinct domain name and maintain a file of refresh pages. Utilization of the "shadow" URL would bring us one step closer to truly universal resource locators.

Comparative assessment of pediatric intensive care in Moscow, the Russian Federation: a prospective, multicenter study.

OBJECTIVE: Comparative assessment of pediatric intensive care. DESIGN: Prospective multicenter study. SETTING: Four pediatric intensive care units in Moscow, the Russian Federation. PATIENTS: Consecutive unselected admissions (n = 583), < or = 14 yrs of age, in a 6-month period. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Effectiveness was defined as the ratio of observed to predicted mortality, based on prediction by Pediatric Risk of Mortality (PRISM) severity of illness scoring. Efficiency (on the day of admission only) depended on either a mortality risk of > 1% or the administration of intensive care unit-dependent therapies. In all four hospitals, observed mortality rates were higher than expected, with a range of standardized mortality ratios between 1.10 and 1.83 (mean 1.32). The excess mortality was found in the low- and medium-risk strata (risk of mortality of < 1% to 15%). Admission efficiency ratings did not fluctuate greatly between institutions (mean 60.4%, range 55.7 to 65.9). CONCLUSIONS: We provided a quantitative description and assessment of pediatric intensive care in Moscow. Moderate efficiency may reflect a low threshold for ICU admission due to poor nurse/patient ratios on the wards. Effectiveness in the low- and medium-risk strata is below standard, as compared with a Western reference population. Excess mortality was concentrated in the low- and medium-risk strata, and can only partially be explained by the inclusion of co-morbidity. Future analysis should focus on specific treatment protocols, protocol adherence, and the determination of infectious and therapeutic complications.

Respiratory failure in congenital heart disease.

Infants and children with congenital heart disease (CHD) present unique difficulties when they develop respiratory failure, either as a consequence of their heart disease, in relation to cardiac surgery, or from infectious causes. Extensive cardiac surgical repairs are now being performed on younger infants with complex anatomy and physiology. The evolution of cardiac surgical technique and perioperative management has revealed the importance of subtle interactions between respiratory physiology and hemodynamic performance.

Pulmonary mechanics in infants after cardiac surgery.

OBJECTIVE: To determine pulmonary mechanical characteristics in neonates after cardiac surgery. DESIGN: A prospective study. SETTING: A 23-bed, pediatric ICU in a 280-bed children's hospital. PATIENTS: Twenty-six infants on the first post-operative day after cardiac surgery. METHODS: Pulmonary mechanics measurements were made during spontaneous breathing, using the esophageal balloon technique and a pneumotachometer. The least mean square method of analysis was used to calculate mechanics. Infants who tolerated withdrawal of mechanical ventilation (group 1) were compared with those infants with respiratory failure (group 2). RESULTS: Spontaneous respiratory rate, tidal volume, and minute ventilation were similar in groups 1 and 2. Lung compliance was decreased, with no difference between groups. Total lung resistance (34.3 +/- 21.6 cm H2O/L.sec in group 1 vs. 136.8 +/- 105.8 cm H2O/L.sec in group 2, p = .002) and resistive work of breathing (33.4 +/- 29.9 g.cm/kg in group 1 vs. 212.9 +/- 173.8 g.cm/kg in group 2, p = .001) were significantly higher in group 2. All infants with a total lung resistance greater than 75 cm H2O/L.sec exhibited respiratory failure (resistance greater than 75 cm H2O/L.sec correlated with respiratory failure, r2 = .73, odds ratio of 70 [confidence interval, 4.4 to 3240], p less than .001). CONCLUSIONS: Increased lung resistance identifies neonates with respiratory failure after cardiac surgery. Pulmonary mechanics testing may be useful in timing withdrawal of mechanical ventilation.

Continuous arteriovenous hemofiltration/dialysis improves pulmonary gas exchange in children with multiple organ system failure.

Continuous arteriovenous hemofiltration with or without countercurrent dialysis (CAVH[D]) improved pulmonary gas exchange in eight children with concomitant renal and respiratory failure. Fluid accumulation had increased patient weight to 65.2 +/- 18.4 (SD) kg before therapy. After 48 h of CAVH(D), weight was reduced to 60.3 +/- 15.5 kg (p less than .02). Similarly, PaO2/FIO2 improved from 137 +/- 99 to 207 +/- 83 (p = .009) with PEEP unchanged or decreased. In patients with net negative fluid balance, pulmonary artery wedge pressure decreased (from 21.3 +/- 3.8 to 14.8 +/- 5.4 mm Hg; p less than .05). Colloid osmotic pressure increased (15.2 +/- 4.6 vs. 21.4 +/- 4.7 mm Hg; p less than .001). BUN and serum creatinine were unchanged. Parenteral nutrition infused was 212 +/- 427 ml/day before CAVH(D), and 1928 +/- 567 ml/day during its use (p less than .0001). CAVH(D) in children with multiple organ failure allowed better caloric intake, and led to improvement in pulmonary gas exchange. We speculate that CAVH(D) improves pulmonary gas exchange by removal of body and lung water, or by enhancing clearance of mediators associated with pulmonary dysfunction.

Toxic shock syndrome with Staphylococcus aureus exit-site infection in a patient on peritoneal dialysis.

Toxic shock syndrome (TSS) associated with exit-site infection but without peritonitis has not been described. We report a case of TSS with an isolated Staphylococcus aureus exit-site infection in a boy on chronic peritoneal dialysis. The exit site had minimal erythema and no purulence. This report re-emphasizes the fact that mildly appearing cutaneous infections in patients with chronic renal failure may have significant consequences. Particular attention should be given to patients who present with constitutional symptoms that may be of short duration. The importance of culturing all sites in such cases is highlighted. The prevalence of TSS with exit-site infections is unknown, but TSS should be considered in patients presenting with similar features.