Pediatrics
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Randomized Controlled Trial Clinical Trial
Topical skin anesthesia for venous, subcutaneous drug reservoir and lumbar punctures in children.
A new topical anesthetic ointment (EMLA, "eutectic mixture of prilocaine and lidocaine was studied in a double-blind, placebo-controlled trial to evaluate its efficiency in alleviating pain associated with venous, subcutaneous drug reservoir and lumbar punctures in children. Pain intensity was scored by the children themselves, using a visual analogue scale in which 0 corresponded to absence of sensation and 10 to the worst imaginable painful sensation. ⋯ In lumbar punctures (14 children studied, 5.5 to 15.3 years of age), EMLA cream was again associated with less pain (1.9 +/- 1.9) than was placebo (5.6 +/- 3.0, P less than .01). It was concluded that the use of EMLA cream substantially reduces pain caused by venous, subcutaneous drug reservoir, and lumbar punctures in children and may therefore be offered to young patients, particularly those repeatedly submitted to such procedures.
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Randomized Controlled Trial Clinical Trial
Prophylactic indomethacin for prevention of intraventricular hemorrhage in premature infants.
The impact of early prophylactic use of intravenous indomethacin on the incidence and severity of periventricular-intraventricular hemorrhage and patent ductus arteriosus in 199 oxygen-requiring premature infants (less than or equal to 1300 g birth weight) was prospectively investigated. The trial was controlled, the infants were randomized, and the investigators were unaware of the group assignments. Patients with minimal (grade I) or no periventricular-intraventricular hemorrhage determined by prestudy echoencephalography were randomized within two birth weight subgroups (500 to 899 and 900 to 1300 g) to receive either prophylactic indomethacin (n = 99) or an equal volume of saline-vehicle placebo (n = 100). ⋯ Results of this study also confirmed a lower incidence of clinically significant patent ductus arteriosus in infants who received prophylactic indomethacin in contrast to those who received placebo (11% v 42%, P less than .001). No significant differences were found between treatment and control groups in the duration of oxygen therapy, mechanical ventilation, or hospitalization or in the incidence of pneumothorax, chronic lung disease, sepsis, necrotizing enterocolitis, retinopathy of prematurity, or death. Early prophylactic indomethacin initiated within 12 hours of delivery is effective in reducing the incidence of intraventricular hemorrhage as well as clinically significant patent ductus arteriosus in very low birth weight premature infants.
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Randomized Controlled Trial Clinical Trial
Successful direct extubation of very low birth weight infants from low intermittent mandatory ventilation rate.
It is common practice to use endotracheal continuous positive airway pressure for various time periods up to 24 hours before attempting extubation in infants who are mechanically ventilated. A few studies in newborns have indicated that airway resistance is increased through small endotracheal tubes. This increases the work of breathing and the likelihood of subsequent ventilatory failure. ⋯ All 13 study infants were successfully extubated without significant apnea or respiratory acidosis. Of the 14 control infants, only seven were successfully extubated; six infants had significant apnea and in one infant respiratory acidosis with pH 7.13 and PCO2 65 developed while receiving continuous positive airway pressure (13/13 v 7/14, P less than .005). The seven infants who failed the preextubation trial of continuous positive airway pressure were later extubated from low intermittent mandatory ventilation rates without significant apnea or respiratory acidosis.(ABSTRACT TRUNCATED AT 250 WORDS)
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Randomized Controlled Trial Comparative Study Clinical Trial
Physician reimbursement by salary or fee-for-service: effect on physician practice behavior in a randomized prospective study.
We used a resident continuity clinic to compare prospectively the impact of salary v fee-for-service reimbursement on physician practice behavior. This model allowed randomization of physicians into salary and fee-for-service groups and separation of the effects of reimbursement from patient behavior. Physicians reimbursed by fee-for-services scheduled more visits per patient than did salaried physicians (3.69 visits v 2.83 visits, P less than .01) and saw their patients more often (2.70 visits v 2.21 visits, P less than .05) during the 9-month study. ⋯ Evaluating visits by American Academy of Pediatrics' guidelines indicated that fee-for-service physicians saw more patients for well-childcare than salaried physicians because they missed fewer recommended visits and scheduled visits in excess of those recommendations. Fee-for-service physicians also provided better continuity of care than salaried physicians by attending a larger percentage of all visits made by their patients (86.6% of visits v 78.3% of visits, P less than .05), and by encouraging fewer emergency visits per enrolled patient (0.12 visits v 0.22 visits, P less than .01). Physicians' interest in private practice, as determined by their career plans, correlated significantly with total number of patients enrolled (r = .48, P less than .05) and total clinic patients seen by each resident during the study (r = .40, P less than .05).(ABSTRACT TRUNCATED AT 250 WORDS)
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Randomized Controlled Trial Clinical Trial
Optimal thermal management for low birth weight infants nursed under high-powered radiant warmers.
Servocontrol of skin temperature for the critically ill premature neonate nursed on a radiant warmer bed has been assumed to be analogous to skin temperature control for infants nursed in convection-warmed incubators. There are significant differences between these two warming techniques, and no definitive data exist to aid the clinical specialist in governing radiant warmer control. Eighteen low birth weight premature infants less than 2 weeks of age were studied under powerful overhead radiant warmers to determine the optimal skin temperature for servocontrol of radiant heater output. ⋯ Oxygen consumption was significantly elevated at 35.5 degrees C (8.62 +/- 0.73 mL/kg/min, mean +/- SEM) compared with 36.5 degrees C (7.30 +/- 0.55 mL/kg/min). Changing servocontrol temperature to 37.5 degrees C produced no further significant decrease in oxygen consumption (7.41 +/- 0.70 mL/kg/min), and nine infants manifested supranormal deep rectal temperatures (greater than 37.5 degrees C). Optimal abdominal skin temperature control at 36.5 degrees C (slightly warmer than previously reported but less than 37.5 degrees C) is recommended for premature neonates nursed on radiant warmer beds.(ABSTRACT TRUNCATED AT 250 WORDS)