Impact of scoliosis surgery on pulmonary function in patients with muscular dystrophies and spinal muscular atrophy.

BACKGROUND: Scoliosis is a common complication of severe neuromuscular diseases. The aim of this study is to determine the impact of posterior spinal fusion on pulmonary function parameters in patients with severe neuromuscular disease at our medical center. METHODS: Retrospective chart review of all patients with severe neuromuscular disease who had posterior spinal fusion between 2012 and 2017 at Texas Children's Hospital. Patients with growing rods, brain injury or malformation, and/or spina bifida were excluded. Pulmonary function measures before and after spinal surgery were determined. RESULTS: A total of 20 eligible patients were identified, 7 with Duchenne muscular dystrophy, 6 with spinal muscular atrophy, 3 with merosin deficient muscular dystrophy, 2 with Charcot-Marie-Tooth, 1 with central core disease, and 1 with dystroglycanopathy. The mean change in vital capacity from pre- to postspine surgery was a loss of 0.63 L for the spinal muscular atrophy patients, a loss of 0.36 L for the Duchenne muscular dystrophy patients, and a gain of 0.23 L for the merosin deficient patients. The difference between spinal muscular atrophy and merosin deficient patients was statistically significant (P = .02) CONCLUSION: In this single-center retrospective study, we found that after spine surgery for scoliosis, all patients with spinal muscular atrophy and most patients with Duchenne muscular dystrophy lost vital capacity, while the patients with merosin deficient muscular dystrophy gained vital capacity. These differences were not associated with differences is respiratory strength, body mass index, or surgical outcomes.

Geospatial analysis for targeting out-of-hospital cardiac arrest intervention.

BACKGROUND: Bystander cardiopulmonary resuscitation (BCPR) provides an opportunity for decreasing cardiac mortality. Rates of out-of-hospital cardiac arrest (OHCA) in which resuscitation was performed vary within cities and across demographics. PURPOSE: To identify contiguous geographic census tracts with high OHCA, low BCPR rates and high-risk demographics to effectively target culturally appropriate community-based intervention planning. METHODS: In 2012, a cohort of 11,389 emergency medical services (EMS) OHCA cases from Houston TX (2004-2011) was linked to census tracts. Multivariable logistic regression analyses were used to identify demographics of contiguous geographic census tracts with the highest OHCA rates. Within these tracts, BCPR rates were evaluated. The combination of information was used to develop a plan to better target interventions. RESULTS: Contiguous census tracts of high OHCA rates were identified; the average rate per 100,000 within versus outside the identified tracts is 106.0 (SD 23.7) to 55.8 (SD 19.7). Tracts with a low BCPR rate (37.7%) relative to a high OHCA rate were identified. In a separate analysis, individuals at highest relative risk of OHCA were found to be African Americans, to have low income or education levels, and to be older individuals. For every 1% increase in African Americans in a census tract, there is an increase of 2.7% in the relative risk of the census tract belonging to a high-OHCA-rate region (95% CI=2.0%, 3.5%). CONCLUSIONS: Geospatial analysis can provide important information on the contiguous areas of high OHCA rates and low BCPR rates with the aim of more effectively targeting interventions and ultimately decreasing cardiac deaths.

Fluid overload is associated with impaired oxygenation and morbidity in critically ill children.

RATIONALE: Fluid overload is common in the critically ill and is thought to contribute to oxygenation failure and mortality. Since increasing disease severity often requires more fluid for resuscitation, it is unclear whether fluid overload is a causative factor in morbidity or is simply an indicator of disease severity. OBJECTIVE: Investigate the association between fluid overload and oxygenation while controlling for severity of illness by daily Pediatric Logistic Organ Dysfunction scores. DESIGN AND SETTING: Retrospective chart review, tertiary children's hospital. PATIENTS AND METHODS: The oxygenation index, fluid overload percent, and daily Pediatric Logistic Organ Dysfunction scores were obtained in a retrospective chart review of 80 patients (mean age 58.7 ± 73.0 months) with respiratory failure. Univariate and multivariate approaches were used to assess the independent relation between fluid overload percent and duration of stay and ventilation. INTERVENTIONS: None. MAIN RESULTS: Higher peak fluid overload percent predicted higher peak oxygenation index, independent of age, gender, and Pediatric Logistic Organ Dysfunction (p = .009). Fluid overload percent ≥15% on any given day was also independently associated with that day's oxygenation index, controlled for age, gender, and Pediatric Logistic Organ Dysfunction (p < .05). Peak fluid overload percent and severe fluid overload percent (≥15%) were both independently associated with longer duration of ventilation (p = .004, p = .01), and pediatric intensive care unit (p = .008, p = .01) and hospital length of stay (p = .02, p = .04), controlled for age, gender, Pediatric Logistic Organ Dysfunction, and in the case of ventilation, respiratory admission. CONCLUSION: This is the first study to report that positive fluid balance adversely affected the pediatric intensive care unit course in children who did not receive renal replacement therapy. While timely administration of fluids is lifesaving, positive fluid balance after hemodynamic stabilization may impact organ function and negatively influence important outcomes in critically ill patients.

Organ dysfunction is associated with hyperglycemia in critically ill children.

OBJECTIVE: To determine the association between organ dysfunction and hyperglycemia in critically ill children receiving intravenous insulin. DESIGN: Retrospective chart review (cohort study). SETTING: Pediatric intensive care unit in a university hospital. PATIENTS: n = 110 patients; inclusion criteria: ICU hospitalization from May 2005 to May 2006; insulin drip to manage hyperglycemia. EXCLUSION CRITERIA: insulin drip <48 h; diabetic patients. MEASUREMENTS: Duration of hyperglycemia: sum of hours of hyperglycemia (> or =126 mg/dl). Hypoglycemia (blood glucose <40 mg/dl). Organ dysfunction was determined per International Pediatric Sepsis Consensus Conference criteria. Multiple logistic regression models determined the association between > or =3 compared to <3 organ dysfunctions and hyperglycemia, hypoglycemia, and mortality, after adjustment for confounding variables (age, gender, PRISM score, vasopressors, steroids). MAIN RESULTS: Organ dysfunction > or =3 compared to <3 after adjustment for confounders was associated with intermittent hyperglycemia of > or =24 h (OR 6.1, CI 1.8-21.2; p = 0.004). Hyperglycemia trended towards significance with mortality [3.2 (CI 0.9-11.6, p = 0.079)]. Hypoglycemia, after adjusting for the above, was not associated with mortality. CONCLUSIONS: Organ dysfunction (> or =3 versus <3) was significantly associated with hyperglycemia for > or =24 h and hypoglycemia. Hyperglycemia trended toward significance with mortality in critically ill children. There was no association between hypoglycemia and mortality.

Automated external defibrillators and simulated in-hospital cardiac arrests.

OBJECTIVE: To test the hypothesis that pediatric residents would have shorter time to attempted defibrillation using automated external defibrillators (AEDs) compared with manual defibrillators (MDs). STUDY DESIGN: A prospective, randomized, controlled trial of AEDs versus MDs was performed. Pediatric residents responded to a simulated in-hospital ventricular fibrillation cardiac arrest and were randomized to using either an AED or MD. The primary end point was time to attempted defibrillation. RESULTS: Sixty residents, 21 (35%) interns, were randomized to 2 groups (AED = 30, MD = 30). Residents randomized to the AED group had a significantly shorter time to attempted defibrillation [median, 60 seconds (interquartile range, 53 to 71 seconds)] compared with those randomized to the MD group [median, 103 seconds (interquartile range, 68 to 288 seconds)] (P < .001). All residents in the AED group attempted defibrillation at <5 minutes compared with 23 (77%) in the MD group (P = .01). CONCLUSIONS: AEDs improve the time to attempted defibrillation by pediatric residents in simulated cardiac arrests. Further studies are needed to help determine the role of AEDs in pediatric in-hospital cardiac arrests.

Post hoc analysis of calfactant use in immunocompromised children with acute lung injury: Impact and feasibility of further clinical trials.

OBJECTIVE: To assess the impact of calfactant (a modified natural bovine lung surfactant) in immunocompromised children with acute lung injury and to determine the number of patients required for a definitive clinical trial of calfactant in this population. DESIGN: Post hoc analysis of data from a previous randomized, control trial. SETTING: Tertiary care pediatric intensive care units. PATIENTS: All children, defined as immunocompromised, enrolled in a multicenter, masked, randomized, control trial of calfactant for acute lung injury conducted between July 2000 and July 2003. INTERVENTIONS: Patients received either an intratracheal instillation of calfactant or an equal volume of air placebo in a protocolized manner. MEASUREMENTS AND MAIN RESULTS: Eleven of 22 (50%) calfactant-treated patients died when compared with 18 of 30 (60%) placebo patients (absolute risk reduction 10.0%, 95% confidence interval [CI] -17.3, 37.3). Among the 23 patients with an initial oxygen index (OI) >/=13 and

Bicarbonate kinetics and predicted energy expenditure in critically ill children.

BACKGROUND: To determine nutrient requirements by the carbon oxidation techniques, it is necessary to know the fraction of carbon dioxide produced during the oxidative process but not excreted. This fraction has not been described in critically ill children. By measuring the dilution of (13)C infused by metabolically produced carbon dioxide, the rates of carbon dioxide appearance can be estimated. Energy expenditure can be determined by bicarbonate dilution kinetics if the energy equivalents of carbon dioxide (food quotient) from the diet ingested are known. OBJECTIVE: We conducted a 6-h, primed, continuous tracer infusion of NaH(13)CO(3) in critically ill children fed parenterally or enterally or receiving only glucose and electrolytes, to determine bicarbonate fractional recovery, bicarbonate rates of appearance, and energy expenditure. DESIGN: Thirty-one critically ill children aged 1 mo-20 y who were admitted to a pediatric intensive care unit at a tertiary-care center were studied. Patients were stratified by age, BMI, and severity score (PRISM III). RESULTS: Fractional bicarbonate recovery was 0.69, 0.70, and 0.63, respectively, for the parenterally fed, enterally fed, and glucose-electrolytes groups, and it correlated with the severity of disease in the parenteral (P < 0.01) and glucose-electrolytes (P < 0.05) groups. Rates of appearance varied between 0.17 and 0.19 micromol . kg(-1) . h(-1) With these data and estimates of the energy equivalents of carbon dioxide (a surrogate for respiratory quotient), energy expenditure was determined. CONCLUSIONS: The 2001 World Health Organization and Schofield predictive equations overestimated and underestimated, respectively, energy requirements compared with those obtained by bicarbonate dilution kinetics. Bicarbonate kinetics allows accurate determination of energy needs in critically ill children.

A validated pediatric transport survey: how is your team performing?

INTRODUCTION: Understanding referring practitioners' satisfaction with pediatric transport services is useful for quality improvement. Formal survey methodology was applied to develop a pediatric transport satisfaction survey. SETTING: Large metropolitan area in the Southwestern United States. METHODS: A four-stage process was used to create a 20-item pediatric transport satisfaction survey. The final survey was analyzed for test-retest and internal consistency reliability, and surveys were mailed to a large practitioner base. RESULTS: The survey encompassed three domains: patient care, accessing the transport system, and communication. Test-retest and internal consistency reliability were good (final Cronbach alpha coefficient of 0.88.) Of the 229 providers responding, 69% were local (<60 miles), and 31% were served by our long distance transport team (>60 miles). Respondents reported that physicians selected the transport team in 82% of cases, whereas 9% reported that the charge nurse decided. Transport team selection was based on: (1) ease of initiation, (2) fastest arrival, (3) presence of a physician on the team, (4) stabilization time at the referring facility, and (5) team providing best follow-up. Satisfaction with our transport service was high, with a median survey score of 83 (interquartile [IQ] range, 74-92). Physicians and nurses reported equal satisfaction. CONCLUSION: Survey design methodology was successfully applied to assess satisfaction with pediatric transport. This transport survey offers a reliable measurement of providers' satisfaction with transport services.

Family experiences during resuscitation at a children's hospital emergency department.

INTRODUCTION: Family presence (FP) during resuscitation is a timely and controversial topic. Family members are becoming part of the resuscitation process. Study objectives included: (1) describe experiences of family members whose children underwent resuscitation in a children's hospital emergency department; (2) identify critical information about family experiences to improve circumstances for future families; and (3) assess mental and health functioning of family members. METHODS: This descriptive, retrospective study involved a 1-hour audio-taped interview of 10 family members using the Parkland Family Presence During Resuscitation/Invasive Procedures Unabridged Family Survey (FS) and investigator-developed questions. Mental and health functioning were assessed using the Brief Symptom Inventory, the Short Form Health Survey version 2, and the Post Traumatic Stress Disorder Scale. Seven family members were present during resuscitation, and three were not present. RESULTS: Five thematic categories were identified: (1) It's My Right to Be There; (2) Connection and Comfort Make a Difference; (3) Seeing is Believing; (4) Getting In; and (5) Information Giving. Family members voiced that it was their right to be present, indicating they had a special connection to the child. Seeing or not seeing the events of the resuscitation affected family members' ability to believe the outcome. Measures of mental and health functioning were similar to population norms. DISCUSSION: Instituting guidelines that facilitate FP may provide mechanisms to ensure that the needs of patients, family members, and health care providers are met during a stressful event.

Reverse transport of children from a tertiary pediatric hospital.

INTRODUCTION: The purpose of this study was to determine the epidemiology and resources used and to study the potential savings of pediatric reverse transport patients. METHODS: A case control study was performed with patients undergoing a reverse or outbound transport from a large, pediatric hospital. Twenty-five children undergoing reverse transport were compared with matched controls. Lengths of stay and costs were compared between the reverse transport and matched control patients. RESULTS: Fifty-two percent of the reverse transport patients returned home, whereas 32% went home for end-of-life care and 16% went to other facilities. The average reverse transport was more than 400 miles and cost $6,064. The reverse transport of these patients did not save pediatric intensive care unit (PICU) days but did result in a shorter hospital stay compared with the matched controls (10 vs. 19 days, P = .03). Decreased utilization of bed days came from less use of intermediate care unit resources. CONCLUSIONS: Pediatric patients undergo reverse transports for a variety of reasons, often for end-of-life care. The ability to reverse transport pediatric patients may not save PICU bed days but may offer pediatric tertiary care hospitals a means to provide more intermediate care bed availability.

Institutional policies on determination of medically inappropriate interventions: use in five pediatric patients.

OBJECTIVE: To describe recent experience using the Texas Advance Directives Act to facilitate care of terminally ill children managed in the two tertiary pediatric hospitals of the Texas Medical Center, Houston, TX. DESIGN: Retrospective chart review. SETTING: Two multidisciplinary pediatric intensive care units in Houston, TX. PATIENTS: Five terminally ill children whose parents were unable to acquiesce to comfort or palliative care. INTERVENTIONS: Implementation of the Texas Advanced Directives Act of 1999. RESULTS: Suspension of interventions thought to be medically inappropriate by the physicians of record in four of the five cases, with transfer of care in one instance. CONCLUSIONS: Use of institutional policies in accordance with the Texas Advance Directives Act may assist in the care of terminally ill children and their families.

Effect of exogenous surfactant (calfactant) in pediatric acute lung injury: a randomized controlled trial.

CONTEXT: Despite evidence that patients with acute lung injury (ALI) have pulmonary surfactant dysfunction, trials of several surfactant preparations to treat adults with ALI have not been successful. Preliminary studies in children with ALI have shown that instillation of a natural lung surfactant (calfactant) containing high levels of surfactant-specific protein B may be beneficial. OBJECTIVE: To determine if endotracheal instillation of calfactant in infants, children, and adolescents with ALI would shorten the course of respiratory failure. DESIGN, SETTING, AND PATIENTS: A multicenter, randomized, blinded trial of calfactant compared with placebo in 153 infants, children, and adolescents with respiratory failure from ALI conducted from July 2000 to July 2003. Twenty-one tertiary care pediatric intensive care units participated. Entry criteria included age 1 week to 21 years, enrollment within 48 hours of endotracheal intubation, radiological evidence of bilateral lung disease, and an oxygenation index higher than 7. Premature infants and children with preexisting lung, cardiac, or central nervous system disease were excluded. INTERVENTION: Treatment with intratracheal instillation of 2 doses of 80 mL/m2 calfactant or an equal volume of air placebo administered 12 hours apart. MAIN OUTCOME MEASURES: Ventilator-free days and mortality; secondary outcome measures were hospital course, adverse events, and failure of conventional mechanical ventilation. RESULTS: The calfactant group experienced an acute mean (SD) decrease in oxygenation index from 20 (12.9) to 13.9 (9.6) after 12 hours compared with the placebo group's decrease from 20.5 (14.7) to 15.1 (9.0) (P = .01). Mortality was significantly greater in the placebo group compared with the calfactant group (27/75 vs 15/77; odds ratio, 2.32; 95% confidence interval, 1.15-4.85), although ventilator-free days were not different. More patients in the placebo group did not respond to conventional mechanical ventilation. There were no differences in long-term complications. CONCLUSIONS: Calfactant acutely improved oxygenation and significantly decreased mortality in infants, children, and adolescents with ALI although no significant decrease in the course of respiratory failure measured by duration of ventilator therapy, intensive care unit, or hospital stay was observed.

Risk factors associated with pressure ulcers in the pediatric intensive care unit.

OBJECTIVE: To identify risk factors that are associated with the development of pressure ulcers in children admitted to the pediatric intensive care unit (PICU). DESIGN: Case control study with no interventions held in a 30-bed PICU of Texas Children's Hospital, Houston. SETTING AND SUBJECTS: The study included 59 patients who developed pressure ulcers in the PICU and 59 patients who were critically ill who did not develop pressure ulcers during the same time period. INSTRUMENTS: Risk assessment data collection tool and Braden scale. METHODS: A comparison was done to identify risk factors between 2 groups of pediatric patients with and without pressure ulcers. A 45-indicator assessment tool was used. Physical assessment including staging of pressure ulcers was performed. RESULTS: Risk factors associated with pressure ulcers include edema (P = .0016), length of stay > 96 hours (P = .001), increasing positive end expiratory pressure (P = .002), not turning the patient or use of a specialty bed in the turning mode (P = .0001), and weight loss (P < .0001). CONCLUSIONS: The presence of edema, increasing length of stay, patients on increasing positive-end expiratory pressure, not turning the patient, use of a specialty bed in the turning mode, and weight loss are associated with the increased risk of development of pressure ulcers in patients in the PICU.

The 2003 national pediatric pressure ulcer and skin breakdown prevalence survey: a multisite study.

OBJECTIVE: The purpose of this study was to document the prevalence of pressure ulcers and other types of skin breakdown in hospitalized children. DESIGN: This descriptive study included documentation of findings from chart reviews and physical assessments of children. SETTING AND SUBJECTS: Nine children's hospitals from throughout the United States participated for a total sample of 1064 children. Subjects were inpatients in the children's hospitals between the ages of neonate to 17 years. INSTRUMENTS: The data collection tools included the interrater reliability quiz, the patient data collection form, FAST data collection software, the Braden Q Risk Assessment Scale, and the Neonatal/Infant Braden Q Risk Assessment Scale. METHODS: Prevalence of pressure ulcers and skin breakdown was measured on a predetermined day during an 8-hour period at each institution. Eight hospitals required a signed informed consent before study participation; 1 hospital's institutional review board waived consent. A physical skin assessment was done on each inpatient, and all pressure ulcers found were staged according to the National Pressure Ulcer Advisory Panel staging system. A chart review was done on all subjects to collect information on patient demographics and potential risk factors. The Neonatal/Infant Braden Q Risk Assessment was scored for infants younger than 1 year old, and the Braden Q Risk Assessment for children 1 year and older. Patient data collection forms were completed, and all data were entered into the FAST data collection software at the end of the study day. Analyses of data and reports were generated from a central site. RESULTS: There were 1,064 children surveyed, with a pressure ulcer prevalence of 4.0% and other skin breakdown prevalence of 14.8%. Ninety-two percent of the pressure ulcers were partial thickness, Stages I and II. Sixty-six percent of the pressure ulcers were facility associated. Locations of pressure ulcers were predominately in the head area 31%, seat area 20%, and foot area 19%. The 3 most common types of skin breakdown were excoriation/diaper dermatitis, skin tear, and IV extravasation. Predominant locations for skin breakdown were seat area 35%, foot area 20%, and upper extremities 18%. CONCLUSIONS: The prevalence of pressure ulcers was low in the pediatric population studied, but skin breakdown prevalence (excluding pressure ulcers) was higher, with 74% of all wound types consisting of excoriation/diaper dermatitis, skin tears, and IV extravasation sites. Future studies are needed to evaluate prevention and treatment options for pressure ulcers and skin breakdown in this population. Repeating this multisite study at intervals may be beneficial to continue to build and modify the benchmark data.

Dead space ventilation in critically ill children with lung injury.

STUDY OBJECTIVE: In children with acute lung injury, there is an increase in minute ventilation (E) and inefficient gas exchange due to a high level of physiologic dead space ventilation (VD/VT). Mechanical ventilation with positive end-expiratory pressure, when used in critically ill patients to correct hypoxemia, may contribute to increased VD/VT. The purpose of this study was to measure metabolic parameters and VD/VT in critically ill children. DESIGN: A cross-sectional study. SETTING: Pediatric ICU of a university hospital. PATIENTS: A total of 45 mechanically intubated children (mean age, 5.5 years). INTERVENTIONS: Indirect calorimetry was used to measure metabolic parameters. VD/VT parameters were calculated using the modified Bohr-Enghoff equation. ARDS was defined based on criteria by The American-European Consensus Conference. MEASUREMENTS AND RESULTS: The group mean (+/- SD) ventilatory equivalent for oxygen (VeqO(2)) and ventilatory equivalent for carbon dioxide (VeqCO(2)) were 2.9 +/- 1 and 3.3 +/- 1 L per 100 mL, respectively. The group mean VD/VT was 0.48 +/- 0.2. When compared to non-ARDS patients (33 patients), the patients with ARDS (12 patients) had a significantly higher VeqO(2) (3.3 +/- 1 vs 2.8 +/- 1 L per 100 mL, respectively; p < 0.05), a significantly higher VeqCO(2) (3.7 +/- 1 L/100 vs 3.1 +/- 1 L per 100 mL, respectively; p < 0.05), and a significantly higher VD/VT (0.62 +/- 0.14 vs 0.43 +/- 0.15, respectively; p < 0.0005). CONCLUSIONS: Critically ill children with ARDS have increased VD/VT. Increased VD/VT was the main cause of the excess of E demand in these patients. Increased metabolic demands, as shown by the VeqO(2), VeqCO(2), and ventilatory support, are the major determinants of E requirements in children with ARDS.

Noncompliance with medical follow-up after pediatric intensive care.

OBJECTIVES: To describe the medical follow-up ordered, the health care utilization, the appointment compliance, and the risk factors associated with noncompliance in patients who are discharged after a pediatric intensive care unit (PICU) stay. METHODS: A prospective, analytic, cohort study of 111 critically ill children, age 1 day to 16 years, who were admitted to a 30-bed PICU in an urban, tertiary-care, pediatric teaching hospital compared children who were compliant with medical follow-up with those who were not. The main outcomes measured were emergent and unscheduled physician visits during the first 6 weeks after hospital discharge; compliance with ordered medical follow-up after hospital discharge; and comparisons of socioeconomic, demographic, and medical need factors between compliant and noncompliant children. Discharge orders for follow-up appointments with general pediatricians and subspecialists were collected from the chart at hospital discharge. Patients were contacted after hospital discharge to determine whether and when they received medical follow-up; 28% were found to be noncompliant. Risk factors associated with noncompliance were evaluated. Emergent and unscheduled physician visits were tracked during the first 6 weeks after hospital discharge. RESULTS: Lack of follow-up orders at hospital discharge did not affect the frequency of emergent visits. Children fell into 2 groups: those who were 100% compliant and those with < or =67% compliance. No socioeconomic or demographic risk factors could be identified between the 2 groups. Compared with the 100% compliant patients, patients who were compliant with < or =67% of appointments were more severely ill, as defined by higher peak pediatric risk of mortality scores during their PICU stay (11.5 vs 8.4), longer PICU length of stays (10.1 days vs 4.6 days), and longer hospital length of stays (25.5 days vs 14 days). Most predictive of noncompliance was the number of medical appointments ordered by physicians. Patients with 3 or more appointments were less likely to be compliant with follow-up. After hospital discharge, children were more likely to visit a primary care physician compared with a subspecialist (95% vs 82%). When patients were ordered to see a specialist, scheduled appointments were much better attended than the recommended appointments (92% vs 67%). CONCLUSIONS: Lack of ordered medical follow-up did not affect emergent visits. In this group of critically ill children, a significant percentage (28%) did not receive timely medical follow-up. No socioeconomic or demographic risk factors were identified in noncompliant children. However, severity of illness (higher peak pediatric risk of mortality score, longer PICU stay, and longer hospital stay) and the number of follow-up appointments ordered were predictors of noncompliance. Potential exists for implementing strategies to improve compliance in identified populations.

Serious and lethal respiratory tract infections of viral etiology in children.

Viruses may lead to serious and lethal pulmonary infections in immunocompetent and immunocompromised children. Series of children with acute respiratory distress syndrome and series of children requiring extracorporeal membrane oxygenation, as well as reported series of nosocomial viral illness, offer an insight into the extent of serious viral disease documented in the medical literature. Series of children with specific viral respiratory illness also will be reviewed, as will the means of diagnosis in these groups of patients. Copyright © 2000 by W.B. Saunders Company.