bluuebunny/crossref_metadata_2025 huggingface dataset:
Disseminated Candidal Infections and Intravenous Hydrocortisone in Preterm Infants
Authors: Botas Carlos M. , Kurlat Isabel , Young Shirley M. , Sola Augusto
Published: December 2021

Background. Intravenous (IV) hydrocortisone (HC) has been used recently in selected preterm infants for hypotension soon after birth. During the same time period that HC was used, there was a marked increase in the incidence of disseminated candidal infections (DCIs).

Objective. To determine whether there is an association between DCI in the first 35 days of life and IV HC in preterm infants.

Research design. A hospital case-control study comparing the exposure of HC between preterm infants with DCI and matched infants without DCI.

Setting. A tertiary level intensive care nursery in a major teaching hospital in San Francisco, CA.

Patients. Seventeen preterm infants with DCI and 25 infants without DCI, with gestational age younger than 28 weeks and birth weight less than 1000 g, inborn and outborn admitted to the intensive care nursery between January 1992 and September 1993.

Methods. All preterm infants diagnosed with DCI at younger than 35 days of age were identified using a perinatal and neonatal database. DCI was defined as a blood, cerebrospinal fluid, or two urine cultures positive for Candida requiring antifungal therapy. A control group of uninfected infants matched for the major risk factors for DCI (gestational age, birth weight, duration of intubation, broad-spectrum antibiotics, and IV alimentation, including lipids and central venous catheters) admitted during the same period was identified using the same database. Postmatching comparison was performed for several other factors to detect any other differences between the groups.

Results. The infants with DCI (n = 17) and control infants (n = 25) had no statistical difference in exposure to the major risk factors for DCI or in postmatching comparison. Ten (59%) of the infants with DCI were receiving HC at the time of infection, whereas four (16%) of the control infants received HC during the first 35 days of life. Infants with DCI were 7.5 times as likely as control infants (95% confidence interval, 5 to 11) to have received IV HC before the onset of fungal infection.

Conclusion. We conclude that the administration of IV HC significantly increases the risk of DCI in susceptible preterm infants younger than 35 days of age. The potentially serious risks of DCI should be considered particularly in the patient selection process for administration of IV HC.
A Controlled Trial of High-Intensity Double-Surface Phototherapy on a Fluid Bed Versus Conventional Phototherapy in Neonatal Jaundice
Authors: Garg A. K. , Prasad R. S. , Al Hifzi I.
Published: December 2021

Objective. To evaluate a simple, relatively inexpensive method using the fluid bed to provide high-intensity double-surface (HIDS) phototherapy and to confirm that the method described is more effective than conventional phototherapy (CPT) in the treatment of neonatal hyperbilirubinemia.

Design. Prospective controlled study.

Method. HIDS phototherapy (26 to 30 µW/cm2 per nanometer) on the fluid bed (n = 22) versus conventional (7 to 10 µW/cm2 per nanometer) phototherapy (n = 28) was used to treat neonates weighing more than 1500 g with hyperbilirubinemia.

Results. After 24 hours of therapy, the bilirubin in the group receiving HIDS phototherapy was significantly lower. The mean rate of fall of bilirubin was 5.34 µmol/L per hour in the group receiving HIDS phototherapy versus 0.7 µmol/L per hour in the group receiving CPT. HIDS phototherapy on a fluid bed was well tolerated.

Conclusion. HIDS phototherapy on the fluid bed is significantly more effective in reducing bilirubin than CPT. It can be easily and economically provided using equipment currently available in most neonatal units.
The Pediatric Report Card for Preventive Services
Authors: Bauchner Howard
Published: December 2021

Health care reform and consolidation within the health care industry has led to greater interest in measuring the quality of care that children receive. Remarkably little is known about measuring the quality of ambulatory services in pediatrics, but nevertheless there is growing interest in "grading" the services provided by health delivery systems. Health care "report cards" are a cornerstone of managed competition—a set of quality indicators that will allow consumers to select the health care plan that best meets their needs.1,2

What should a report card for pediatric preventive services include? Traditionally, many insurers have reported immunization rates, but little else with respect to children.3,4
Letters to the Editor
Authors: Anderson Philip O.
Published: December 2021

The Committee on Drugs' revised statement on drugs and chemicals in breast milk1 will undoubtedly be widely used as an authoritative source of information for counseling nursing mothers. However, it has some noteworthy shortcomings:

Discussion of the effects of drugs on lactation is inadequate. For example, combination oral contraceptives (none of which contain progesterone as is stated) are accompanied by the somewhat misleading comment, "... decrease in milk production and protein content (not confirmed in several studies)."
Retinopathy of Prematurity and Cortical, Blindness
Authors: Good William V. , Silverman William A. , Johnson-Kuhn Jenna , Murphy Dennak
Published: December 2021

We read with great interest the article by Keith and Doyle,1 "Retinopathy of Prematurity in Extremely Low Birth Weight Infants." We are writing to ask the authors to comment on whether any babies who graduated from their nursery suffered cortical visual impairment.

In northern California in a registry maintained by the Blind Babies Foundation, we found that 7% of the visually impaired children with extremely low birth weight had cortical visual impairment as the etiology of their low vision.
Increased Plasma Levels of Pancreatic Polypeptide and Decreased Plasma Levels of Motilin in Encopretic Children
Authors: Stern H. Patrick , Stroh Suzanne E. , Fiedorek Stephen C. , Kelleher Kelly , Mellon Michael W. , Pope Sandra K. , Rayford Phillip L.
Published: December 2021

Objective. Abnormalities of hormones affecting gastrointestinal motility have been found in "functional" disorders of the gastrointestinal system in adults. One such disorder of childhood, encopresis, is frequently associated with constipation, the treatment of which often eliminates the soiling. We hypothesized that hormones affecting gastrointestinal motility were different between encopretic patients and matched controls.

Methods. Ten encopretic patients were matched by age, race, and sex with controls who had no history of encopresis or constipation. After an overnight fast, each child consumed a meal of Ensure, the amount of which was based on body weight. Plasma levels of gastrin, pancreatic polypeptide, cholecystokinin, motilin, thyroxine, estrogen, and insulin were measured 20 and 5 minutes before the meal, and 5, 10, 15, 30, 45, 60, 90, 120, 150, and 180 minutes after the meal.

Results. Postprandial levels of pancreatic polypeptide remained consistently higher and peaked earlier (P < .05) for encopretic patients. The motilin response was lower (P < .03) for encopretic children than for controls.

Conclusions. We conclude that pancreatic polypeptide and motilin responses to a meal are different in encopretic children than in children in the control group. These gastrointestinal hormone findings may in part explain and/or be the result of the severe constipation that frequently underlies the fecal soiling found in these patients. These findings also suggest the motility of the stomach and small intestine may be abnormal in encopresis.
Unexpected Death From Enterocolitis After Surgery for Hirschsprung's Disease
Authors: Marty Terri L. , Matlak Michael E. , Hendrickson Margo , Black Richard E. , Johnson Dale G.
Published: December 2021

Unanticipated death from enterocolitis occurred in five children 3 weeks to 20 months after uncomplicated reconstruction for Hirschsprung's disease. In each case the presenting symptoms of enterocolitis were mild and were misinterpreted by examining physicians. Within 2 to 12 days of onset of symptoms, unexpected death occurred. Although fatal enterocolitis is a well-known complication of Hirschsprung's disease, emphasis is usually placed on preoperative enterocolitis. Fatal postoperative enterocolitis is not a new entity associated with Hirschsprung's disease, but physician awareness of this possibility is obviously deficient. We strongly recommend extensive parent education and better postoperative communication between the surgeon and the referring physician.
COMPARISON OF INTRAMUSCULAR AND INTRAVENOUS QUININE FOR THE TREATMENT OF SEVERE AND COMPLICATED MALARIA IN CHILDREN
Authors: Schapira A , Solomon T , Julien M
Published: December 2021

Intravenous (IV) quinine is the standard treatment for severe malaria where chloroquine resistant Plasmodium falciparum is found. Because of the advantages of intramuscular (IM) administration, a study was performed to compare these methods of administration in children with severe and complicated malaria. The study population was children from 6 months to 7 years of age, all of whom had asexual Plasmodium falciparum in the blood smear and at least one of the following: rigorously defined cerebral malaria; probable cerebral malaria; hyperparasitemia; or severe malaria. Exclusions included those who had: received quinine within a week; received an excessive dose of chloroquine within 48 hours; a history of quinine intolerance; or signs of circulatory shock or hemorrhagic diathesis.

Patients were randomly allocated to one of two treatment groups: 1) quinine dihydrochloride administered intravenously with an initial loading dose of 20 mg/kg in 5% glucose, 20 mL/kg over 4 hours, followed by 10 mg/kg in 5% glucose, 10 mL/kg intravenously over 2 hours every 8 hours; 2) quinine dihydrochloride 10 mg/kg by deep IM injection at alternating sites every 8 hours. A loading dose was applied by repetition of the initial dose after 2 hours. Treatment was changed to oral medication 10 mg/kg every 8 hours when they were well enough to do so.

There were 47 patients in the IV group and 57 in the IM group. The two groups were comparable in all aspects including malnutrition, anemia, and splenomegaly. Seventeen percent (17%) of the IV group died and 7% of the IM group died. The mean parasite clearance, fever clearance, and coma clearance times were similar in both groups. There were two sterile abscesses in the IM group.

The authors conclude that IM quinine is as effective as IV in children with severe and complicated malaria.
Ribavirin Therapy: Implementation of Hospital Guidelines and Effect on Usage and Cost of Therapy
Authors: Feldstein Thomas J. , Swegarden Jon L. , Atwood Gerald F. , Peterson Charles D.
Published: December 2021

Objective. The American Academy of Pediatrics (AAP) recommends that ribavirin be reserved for infants who are severely ill and who are at high risk of morbidity and mortality, based on underlying clinical conditions. The purpose of this study was to evaluate current ribavirin use in our institution, implement hospital-specific guidelines for use, develop a prospective surveillance system to monitor ribavirin therapy, and evaluate the impact of these guidelines on subsequent use and cost of therapy.

Methods. Ribavirin use was compared with the recommendations of the AAP. Results were presented to the professional staff, and hospital guidelines were implemented. Ribavirin therapy was reevaluated in a 2-year period after hospital guidelines were implemented.

Results. In the initial evaluation period, only 67% of the ribavirin recipients met the AAP guidelines for use, and 19% received an inappropriate treatment regimen. The total cost and billed patient charges for ribavirin recipients who did not meet the guidelines for use in period 1 was $60 638 and $127 940, respectively. Over the next 2 years (period 2) after the implementation of hospital guidelines, the percentage of patients who received ribavirin decreased 35%, and approximately 96% of ribavirin recipients met the established criteria. Based on the decrease in the percentage of patients who received ribavirin in period 2 (41% versus 63%), the estimated cost avoidance and reduction in billed patient charges in period 2 was $55 540 and $117 334, respectively. This represents an estimated reduction in hospital costs and billed patient charges of $46 283 and $97 778 per 100 admissions for acute bronchiolitis.

Conclusions. Before the implementation of hospital guidelines for use, a substantial percent of patients received ribavirin not consistent with the recommendations of the AAP. Following the adoption of a modified version of the AAP guidelines for our institution and the use of a multidisciplinary surveillance system for monitoring ribavirin therapy, we observed a substantial decrease in the overall ribavirin use. This has resulted in a significant savings in terms of cost avoidance and reduced billed patient charges.
The Colic Debate
Authors: Hill David J. , Hosking Clifford S.
Published: December 2021

We read with interest the excellent paper by Wolke et al1 and the accompanying commentary by Carey.2 Wolke's paper supported Carey's previous publications suggesting an important role for disturbed parent/infant interaction in this common condition. However, we believe the comments by Carey2 that "an alternative explanation for colic is cow milk allergy, which accounts for only a small proportion of colicky infants," is far too dismissive of data published regarding an important role for diet in colic of infancy.3-5
Letters to the Editor
Authors: Di Maio Vincent J. M.
Published: December 2021

In the editorial by Little and Brooks,1 the authors refer to "new information" that two of the five deaths in the study by Steinschneider2 were in fact murders. This brings into question the conclusions of the Steinschneider study, the relationship between apnea and sudden infant death syndrome (if any) and, perhaps, the use of home monitors. All of this was not "new information" to the Forensic Pathology community. That the two deaths in the study by Steinschneider were probably homicide was stated in a chapter in Clinics in Laboratory Medicine, a letter to Pediatrics, and in the textbook Forensic Pathology.3
Letters to the Editor
Authors: Little George A. , Brooks John G.
Published: December 2021

We thank Drs DiMaio and Southall for drawing our attention to their publications; they and their associates obviously accept the unthinkable.1 We are quite sure that not everyone does as readily; murder is not a nice thought.

Dr DiMaio's letter2 was followed with a reply by Dr Kelly.3 Both refer to the 1978 paper by Steinschneider,4 but with different emphasis. The first, speaking from the perspective of a forensic pathologist, concluded that infanticide was the most likely cause of death.
Selection Bias in Case-Control Studies of Severe Varicella Infection
Authors: Weiss Noel S.
Published: December 2021

Two features of the case-control study by Dowell and Bresee1 on severe varicella as a possible adverse consequence of using corticosteroids limit the inferences that can be drawn from the results:

1. The investigators identified only 19 children with severe varicella who did not have leukemia or a history of renal transplantation, conditions associated with substantial immune suppression;

2. Other conditions associated with immune suppression may have been present in those 19 children to a greater extent than in control children.
The Surgeon and Emergency Medical Services for Chi
Authors: Cooper Arthur , Barlow Barbara
Published: December 2021

A central focus of emergency medical services for chi is the critically injured child, whose potential for recovery is great. Yet trauma remains the leading cause of mortality and morbidity among American children 1-14 years of age. Much unnecessary death and disability can be avoided through aggressive professional and public education in pediatric advanced life support and injury prevention. As the primary-care physician of the critically injured child, the surgeon plays a leading role in ensuring that trauma and emergency medical services systems are optimally prepared to meet the dual challenges of providing optimal pediatric trauma care and obviating the need for such treatment through all means possible.
RATS!
Authors: L. J. F.
Published: December 2021

The mouse-is-a-little-man premise has spawned unprecedented increases in environmental regulation (purportedly to protect us from cancer) and has contributed substantially to the cost of most goods and services, insurance premiums, legal fees, and federal taxes while reducing job opportunities and incentives for innovation.
Cerebrospinal Fluid Analysis in Systemically Ill Children Without Central Nervous System Disease
Authors: Carraccio Carol , Blotny Krystyna , Fisher Margaret C.
Published: December 2021

Objective. Experience led us to question the applicability of standards for normal cerebrospinal fluid (CSF), originally developed in healthy children, to children with systemic illness but without central nervous system (CNS) infection. The purpose of this study was to test our hypothesis that systemically ill children, in the absence of CNS infection, have an elevated CSF white blood cell count and a greater percentage of neutrophils than accepted norms.

Methods. We enrolled 345 patients in the following diagnostic categories: infants 1 month of age or younger with possible sepsis (n = 95), patients older than 1 month of age with possible sepsis (n = 155), patients with a focus of infection in close proximity to the CNS (n = 51), and patients presenting with seizures and fevers (n = 45). Sociodemographic data and results of CSF examination were abstracted from the medical records. Statistical analysis systems were used for data processing.

Results. The CSF white blood cell count did not significantly differ from standards except for a lower mean count in the group presenting with seizures. The percent of CSF neutrophils was significantly greater than standards, however, for those patients older than 1 month of age with possible sepsis, those with a focus of infection in close proximity to the CNS, and those presenting with seizures. Data analysis by quantiles shows only 25% to 50% of patients, in each of the diagnostic categories, meeting the current definition of normal CSF neutrophil count.

Conclusions. Our results show that a mean of at least 5% neutrophils may be present in the CSF with a diagnosis of fever without a source, a focus of infection in close proximity to the CNS, or a seizure with fever in the absence of CNS infection. These data support tailoring treatment based on clinical assessment rather than what is considered an abnormal CSF neutrophil count by current standards.
Newborn Acoustic Cry Characteristics of Infants Subsequently Dying of Sudden Infant Death Syndrome
Authors: Corwin Michael J. , Lester Barry M. , Sepkoski Carol , Peucker Mark , Kayne Herbert , Golub Howard L.
Published: December 2021

Objective. To test the hypothesis that the occurrence of a neonatal cry exhibiting a high first formant is a risk factor for sudden infant death syndrome (SIDS) and to evaluate the association between SIDS and other acoustic cry variables.

Method. We recorded cries and obtained medical and demographic data for 21 880 apparently healthy term newborns. Two cries were recorded between days 2 and 7 of life, after a painful stimulus at the time of routine blood drawing. Acoustic variables were measured with an automated computer-based analysis system. Twelve infants died of SIDS. Age at death ranged from 19 days to 6.5 months. Autopsies were performed in all cases. At least one cry was analyzed for all 12 infants who died of SIDS and 20 167 infants without SIDS. Two cries were analyzed for 9 infants who died of SIDS and 14 235 infants without SIDS.

Results. Newborns whose first cries exhibited a high first formant were more likely to die of SIDS than infants whose first cries did not have this characteristic (relative risk, 3.5; 95% confidence interval [CI] 1.1 to 12). The relative risk for SIDS increased to 8.8 (95% CI, 2.2 to 35) for newborns whose second cries showed that this characteristic persisted. Newborns with the combination of both a high first formant and a high number of mode changes on both of two cries had a relative risk of 32 (95% CI, 8.7 to 120).

Conclusions. We have shown an association between alterations in neonatal cry acoustics and SIDS. Cry analysis represents a potentially important research tool that, when studied in relation to other physiologic measures, may lead to an improved understanding of SIDS.
NUTRITION, IMMUNITY, AND INFECTIONS: T LYMPHOCYTE SUBPOPULATIONS IN PROTEIN-ENERGY MALNUTRITION
Authors: Ozkan H , Olgun N , Sasmaz E
Published: December 2021

This study was a case-control study of 44 children ages 3 to 24 months. The purpose of the study was to compare the humoral and cellular immunity of 29 patients (Group I) who were less than the 3rd percentile for weight by Turkish standards versus a control group of 15 patients (Group II) with weights between the 25th and 90th percentiles. The Group I patients were considered to have protein energy malnutrition (PEM) with various degrees of severity based on a Turkish classification method established by Dogramaci and Wray in 1958. None of the Group I patients had frank kwashiorkor, but 19 had bronchopneumonia, six had gastroenteritis, and four had both forms of infection at the time studies were done. Detailed immunologic evaluation was carried out on all the subjects including IgG, IgM, IgA, C3, mature T lymphocytes (CD3+), helper/inducer T Lymphocytes (CD4+) and suppressor/cytotoxic T lymphocytes (CD8+). The authors chose to study patients with PEM and infections because the immune response is more likely to be suppressed at this time. In the PEM group all of the immunoglobulins (IgG, IgM, IgA) were significantly elevated over the controls level (P < .01). This hyperimmunoglobulinemia state has been previously reported and could be secondary to reduced suppressor T lymphocytes (C8+). C3 complement levels were also significantly lower (P < .01) than controls, which have been previously noted. These low C3 levels could be secondary to decreased production from the liver or increased utilization with an intercurrent infection. In evaluating the lymphocyte series CD3+, CD4+, and CD8+ were all significantly reduced while CD4/CD8 levels were normal.
Implementation of the Community Outpatient Practice Experience in a Large Pediatric Residency Program
Authors: Recchia Kimberlee C. , Petros Teresa M. , Spooner S. Andrew , Cranshaw Janet L.
Published: December 2021

Objectives. To determine the feasibility of implementing the Community Outpatient Practice Experience (COPE), a community-based continuity program, in a large, tertiary-care-oriented pediatric residency; to assess the impact of the continuity program on pediatric residents' experience; and to compare the experience in a variety of community practice settings.

Settings. Continuity clinic settings included a hospital-based residents' group practice (RGP) clinic (1989 through 1991) and a community-based program in which each resident was paired with a practicing pediatrician in the community (1991 through 1993). Community practice types included publicly funded clinics (n = 9), private practices (n = 38), and managed-care practices (n = 14). In all settings, residents spent half a day per week in continuity activity.

Methods. Measures of residents' experience (patient encounters, patient age distribution, and diagnostic mix) were compared in both settings and among community practice types. RGP data were derived from a patient scheduling database, and COPE data were obtained from patient encounter records submitted by each resident.

Results. Residents in RGP (108.5 resident years) had 5294 encounters with 1568 patients. In COPE (102.5 resident years), 21 978 encounters with 19 235 patients occurred. COPE residents saw significantly more patients per session (6.2 vs 1.7) than residents in RGP. The mean patient age in COPE was significantly higher than RGP (5.3 vs 2.6 years). A greater proportion of encounters in RGP were for health supervision (61% vs 30%), but a greater number of health supervision encounters per resident occurred in COPE. There was a higher proportion of patients with chronic disease in RGP (38% vs 7%), but a greater number of patients with chronic disease was seen per resident in COPE. Analysis of COPE data by practice type showed fewer patient encounters per session and a younger patient age in publicly funded sites than in private- or managed-care practices. The proportion of health supervision encounters was greatest in publicly funded sites, but the greatest number of health supervision encounters per resident occurred in managed-care practices.

Conclusions. We successfully integrated a large-scale community-based continuity experience into a large, tertiary-care-oriented pediatric residency program. We present COPE as an alternative to the hospital-based continuity clinic and suggest it as a model for improving residents' primary-care experience.
Adolescent Development and Transitions to Motherhood
Authors: Flanagan Patricia J. , McGrath Margaret M. , Meyer Elaine C. , Coll Cynthia T. Garcia
Published: December 2021

Objective. To use both qualitative and quantitative methods to examine the experience of motherhood during adolescence and to evaluate developmental influences on the concept of maternal role.

Design. (1) A grounded theory approach was initially used to generate a hypothesis. Focus groups and individual interviews were analyzed for concept and theme. (2) A quantitative method using correlational analysis was used to test the hypothesis generated by qualitative study. A structured interview using five specific, scored questions about self and about motherhood was used to examine the relationship between developmental complexity of responses to questions about self and questions about motherhood.

Setting and Participants. The qualitative study involved group and individual interviews with 42 teenage mothers. The quantitative study involved individual interviews with 25 mothers, ages 14 to 18 years, at an innercity clinic for young parents and their infants. Race and ethnicity were heterogeneous, and 100% received Aid to Families With Dependent Children.

Results. The major hypothesis generated from the qualitative analysis was that an adolescent mother's conceptualization of her maternal role is related to her own psychosocial and cognitive development. The quantitative study revealed a strong correlation between the developmental complexity of responses to questions about self and the complexity of responses to questions about motherhood (r2 = .81).

Conclusion. The experience of motherhood and the conceptualization of the maternal role in adolescence is related to young mothers' psychosocial cognitive development.
Acute and Chronic Intestinal Motor Activity Responses to Two Infant Formulas
Authors: Jadcherla Sudarshan R. , Berseth Carol Lynn
Published: December 2021

Objective. Preterm formulas are nutritionally better for preterm infants; however, it has been observed that these formulas cause more feeding intolerance than do regular formulas. Because intestinal motor activity is responsible for the aboral movement of intraluminal nutrients, the purpose of this study was to evaluate intestinal motor activity responses to two infant formulas: 84 and 100.8 J/oz.

Study Design and Results. Intestinal motor activity was recorded in 52 preterm infants who had never been fed and who were randomly assigned to receive small enteral feedings (24 mL/kg per day) for 10 days with one of two commonly used infant formulas. In a subset of 26 of these infants, acute motor responses to both formulas were also evaluated. At the end of the study period, motor activity during fasting did not differ between the two groups of infants. However, motor responses during feeding to the two formulas differed significantly. When infants were fed for the first time, their motor activity increased compared with fasting when they were fed the 84-J/oz formula but decreased when they were fed the 100.8-J/oz formula. These differences in motor responses to the two formulas were not present 10 days later. These differences in motor responses to the 100.8- and 84-J/oz formulas were even more pronounced among the 7 infants who subsequently developed feeding intolerance to the 100.8-J/oz formula during the 10-day study period.

Conclusion. Inhibition of motor responses to calorically denser formulas during active feeding in a subset of preterm infants may underlie the feeding intolerance they experience when they are fed these formulas. However, this inhibitory response diminishes with age, suggesting that denser formulas can be reintroduced later in life to these infants.
E.H. Christopherson Lecture: Lessons for the United States From the Worldwide Child Survival Revolution
Authors: Taylor Carl E.
Published: December 2021

It is time to apply in the United States' principles that are emerging from a series of World Summits and United Nations Conferences on Children, Environment, Population, Women, and Social Development. After years of top-down programs supported by international agencies, which have made some significant contributions in promoting activities such as childhood immunization but are having problems of sustainability, we need to focus now on integrated human development. The past tendency in international assistance to concentrate on economic development has not helped the people in greatest need. There is growing realization that what improves the quality of life most is what people do for themselves. Sustainability requires social mobilization at the local level. There are thousands of integrated, social development projects around the world that demonstrate the power of community-based, participatory approaches and we know how such local programs can be made to work under any political or economic system. What we haven't learned is how to "go to scale" in extending such projects to cover larger populations. A promising approach11 seems to be using successful local projects upgraded into Centers for Action Learning to promote the adaptation of science-based innovations to everyday life in a whole region of a country.
Extraordinarily High Eosinophilia and Elevated Serum Interleukin-5 Level Observed in a Patient Infected With Paragonimus westermani
Authors: Kan Hiroaki , Ogata Takayuki , Taniyama Akihiko , Migita Masahiro , Matsuda Ichiro , Nawa Yukifumi
Published: December 2021

Objective. Although eosinophilia is one of the typical clinical features of some helminth infections, the degree of eosinophilia in helminthiasis is usually 10% to 30% with a total white blood cell count of 10 000 to 20 000/mm3. Here we report a case of extraordinarily high eosinophilia (91%; absolute eosinophil count, 84 000/mm3) caused by Paragonimus westermani infection. To determine the mechanisms of eosinophilia, the levels of several eosinophilopoietic cytokines in the patient's sera were measured during the course of treatment.

Methods. Serum levels of three cytokines, granulocyte-macrophage colony-stimulating factor, interleukin-3 (IL-3), and IL-5 were measured by enzyme-linked immunosorbent assay using commercial kits or our own assay system for IL-5.

Results. Although the kinetic changes of IL-5 correlated well with eosinophilia, the serum IL-3 level remained below the detection level throughout the period examined. Although the granulocyte-macrophage colony-stimulating factor level was twofold to threefold higher than the normal bevel, its kinetics did not parallel the degree of eosinophilia.

Conclusions. These results show that Paragonimus westermani infection can induce an extraordinarily high level of eosinophilia with an associated increase in IL-5 production. Immunoserologic diagnosis for parasitic diseases should be included in the differential diagnosis of eosinophilia.
Fruit Juice
Authors: Lifschitz Carlos H.
Published: December 2021

In their article "Carbohydrate Absorption From Fruit Juice in Young Children," Smith et al1 confirm the fact that the mix of carbohydrates, rather than the type or concentration alone, have an overriding effect in determining their degree of intestinal absorption. In his commentary, Dr Klish suggests that "if used in reasonable amounts...it probably makes no difference what fruit juice is fed."2

Dietary fiber is defined as "nondigestible carbohydrates and lignins." The American Academy of Pediatrics3 states that high-fiber diets effectively treat constipation...and that "possibly 75% of children in the United States eat less than the recommended amounts of fruits and vegetables."
Letters to the Editor
Authors: Futterman Donna , Hein Karen , Dell Ralph B.
Published: December 2021

Adams et al ask for data on the impact of age on risk of HIV infection. We did not collect data on the age of sexual partners and so are not able to follow-up on this intriguing idea. We did collect information on age at first intercourse in the second half of the study. This variable was significantly correlated with HIV status (r = 0.187, r2 = 0.03 or 3% of the variance), but when it was available for entry into the logistic equation, other variables entered first and age at first intercourse quickly lost significance.
MECONIUM ANALYSIS TO ASSESS FETAL EXPOSURE TO NICOTINE BY ACTIVE AND PASSIVE MATERNAL SMOKING
Authors: Randolph Christopher
Published: December 2021

Fetal exposure to tobacco smoke may be considerable, even for fetuses of passive maternal smokers.
FACTORS IN CHILDHOOD AS PREDICTORS OF ASTHMA IN ADULT LIFE
Authors: Bell Thomas
Published: December 2021

The authors speculate that reducing frequency and severity of attacks might prevent symptoms in later life and they discuss the implications for use of corticosteroids. Other risk factors are examined and I encourage you to read this article in detail.
RESPIRATORY SYNCYTIAL VIRUS LUNG INFECTION IN INFANTS: IMMUNOREGULATORY ROLE OF INFECTED ALVEOLAR MACROPHAGES
Authors: Greos Leon S.
Published: December 2021

Alveolar macrophages are infected by RSV in vivo and coexpress potent immunomodulatory molecules that potentially regulate local immune response or lung injury caused by RSV infection.
T LYMPHOCYTES ADHERE TO AIRWAY SMOOTH MUSCLE CELLS VIA INTEGRINS AND CD-44, AND INDUCE SMOOTH MUSCLE CELL DNA SYNTHESIS
Authors: May Kathleen , Liu Andrew
Published: December 2021

The ability of activated T cells to adhere to ASM and to further induce DNA synthesis in growth-arrested cells may have important implications for smooth muscle in the asthmatic lung. Perhaps the smooth muscle cell itself plays a role in the inflammation of asthma. In addition, an activated T cell population in the lungs which stimulates ASM to produce DNA could possibly lead to hypertrophy of this cell type.
PULMONARY FUNCTION, ACTIVATED T CELLS, PERIPHERAL BLOOD EOSINOPHILIA, AND SERUM ACTIVITY FOR EOSINOPHIL SURVIVAL IN VITRO: A LONGITUDINAL STUDY IN BRONCHIAL ASTHMA
Authors: Sachs Martin I.
Published: December 2021

A correlation does exist between changes in T cell activation, the number of eosinophils, serum activity towards eosinophil survival in vitro, and the degree of air flow obstruction in patients with asthma. This data confirms the results of Barry Kay published in 1990, but goes further to state that not only will the number of activated T cells and eosinophils decrease with improving function but the opposite was true as well; in other words, declining lung function was associated with a rise in activated T cells, eosinophils, and serum levels of eosinophils surviving. The study was consistent for both 16 patients with "allergic" asthma and the four patients who did not appear to have a significant allergic component to their asthma.
STEROID-RESISTANT ASTHMA: CELLULAR MECHANISMS CONTRIBUTING TO INADEQUATE RESPONSE TO GLUCOCORTICOID THERAPY
Authors: Raub Jeff , Spahn Joseph
Published: December 2021

The data from this study suggests that diminished GCR binding affinity may in part be responsible for poor steroid responsiveness in those asthmatics with SR asthma. This defect is an acquired and reversible phenomena which is likely the result of exposure to cytokines (IL-2 and IL-4) involved in the pathogenesis of asthma.
ANTIGEN AVOIDANCE IN A MOUNTAIN ENVIRONMENT: INFLUENCE ON BASOPHIL RELEASABILITY IN CHILDREN WITH ALLERGIC ASTHMA
Authors: Segal Allen T.
Published: December 2021

Prolonged stays in a mite-free environment by mite-sensitive children with asthma produce a significant improvement in bronchial hyperreactivity and in antigen-induced histamine release from basophils.
ACCURACY OF MINI PEAK-FLOW METERS (PFMS) IN INDICATING CHANGES IN LUNG FUNCTION IN CHILDREN WITH ASTHMA
Authors: Bell Thomas
Published: December 2021

The article includes printouts of longitudinal comparisons of spirometry and specific mini-PFM readings from the individual subjects; the visual conclusions are inescapable: the mini-PFM is crude compared with spirometry in this study.
A PROSPECTIVE RANDOMIZED STUDY OF CONTINUOUS VERSUS INTERMITTENT NEBULIZED ALBUTEROL FOR SEVERE STATUS ASTHMATICUS IN CHILDREN
Authors: Chipps Bradley E.
Published: December 2021

Purpose of the Study. Comparison of continuously nebulized albuterol (0.3 mg/kg/hour) to intermittent hourly albuterol (0.3 mg/kg/dose) in the treatment of status asthmaticus.

Population. Seventeen patients (average, 5 years; range, 1.8 to 16 years) admitted to the Pediatric Intensive Care Unit (PICU) with severe status asthmaticus (asthma scored >5, range 0 to 10) who were nonresponsive to outpatient management with β-agonist, oxygen, corticosteroid, and theophylline.

Methods. Randomized, nonblinded trial using small volume nebulizer for both modalities of treatment. The minimum albuterol dose was 5 mg/hour and maximum dose was 10 mg/hour.

Results. The two groups did not differ in demographics, vital signs, or blood gas results. Improvement in clinical score was significant (8 to 6) in the continuous group as compared with the intermittent nebulized group (7 to 6.8) during the first 4 hours of therapy. The mean time to reach an asthma score of <5 was 12 hours (range, 4 to 24 hours) for continuous group compared with 18 hours (range, 12 to 24 hours) for the intermittent group. One patient in the intermittent group failed to respond after 12 hours and was removed from the protocol. Another patient in the intermittent group was readmitted to the PICU 60 hours after discharge for a severe episode of status asthmaticus. No significant changes in electrocardiogram, vital signs, on lab data occurred except for hypokalemia in one patient in the continuous group who was not given supplemental potassium. The respiratory therapist's time commitment for the continuous group was approximately 50% less than for intermittent therapy group.
REASSESSING THE THERAPEUTIC RANGE FOR THEOPHYLLINE ON LABORATORY REPORT FORMS: ANOTHER PERSPECTIVE
Authors: Kamada Alan K.
Published: December 2021

The therapeutic utility of theophylline and the recommended range for serum concentrations are debated in a series of three editorials by noted contributors in this area. In the first, it is pointed out that the role of theophylline has evolved into an "adjunctive" therapy for asthma and chronic obstructive pulmonary disease. Serum concentrations of 10 to 15 µg/mL do not sacrifice significant clinical benefit, whereas there is increased risk for adverse effects at higher concentrations. Changing laboratry report forms to designate a lower therapeutic range of 5 to 15 µg/mL for an increased margin of safety (with >20 µg/mL continuing as the lower limit of the toxic range) is advocated and a stepwise approach for implementing this change is proposed.

The second paper supports the view that theophylline remains more important than a third- or fourth-line agent in the treatment of asthma, particularly in selected patients. A higher target serum concentration range of 10 to 15 µg/mL may be desirable in more severe asthmatics (requiring oral steroids despite treatment with inhaled steroid), those with nocturnal symptoms, acute exacerbations requiring hospitalization and mechanical ventilation, and in patients for whom this is a more economical or preferable therapy. In these patients a serum concentration of 5 µg/mL may be too low to achieve sufficient benefit. Designation of "10 to 15 µg/mL (5 to 20)" as the therapeutic range is suggested to emphasize the midrange as the target while indicating that levels between 5 and 20 µg/mL are acceptable, although not ideal from either an efficacy or safety standpoint.

In the third and final viewpoint presented, much data supporting the efficacy of theophylline in the treatment of chronic asthma and its relationship to serum concentrations are presented. Evidence for potential anti-inflammatory effects of theophylline is also reviewed. Severe toxicity, a rare event, is noted to be not a result of serum concentrations slightly above the therapeutic range, but from massive overdosage and/or drug interactions or concomitant illnesses that alter elimination of the drug. No changes in the recommended therapeutic range of theopylline, which might alter its effectiveness, are proposed. Rather, more careful use and monitoring through education of prescribers is advocated.
EFFICACY OF CROMOGLYCATE IN PERSISTENTLY WHEEZING INFANTS
Authors: Joos Thad H.
Published: December 2021

Purpose of the Study. To evaluate the effectiveness of sodium cromoglycate in the treatment of persistent wheezing in children ages 4 to 12 months.

Study Population. Thirty-one asthmatic infants without such complicating factors as gastroesophageal reflux, cystic fibrosis, bronchopulmonary dysplasia, etc, were enrollled. Sixteen received active medication and 15 received placebo.

Methods. All 31 infants were observed for 3 weeks before the final enrollment with symptom scores recorded based on cough, wheeze, thoracic indrawing, and sleep pattern. Any noticeable problems were treated with albuterol delivered by a nebulizen and tightly fitting face mask.

Pulmonary function parameters were determined by the "squeeze technique" on all enrollees.

For the next 6 weeks, 16 infants received 40 mg of sodium cromoglycate in 4 mL solution via the nebulizer three times a day and 15 infants received 4 mL of normal saline three times a day.

Symptom scores were meticulously recorded and again pulmonary function studies were performed.

Findings. There were no significant differences noted between the sodium cnomoglycate group or the placebo group that led the investigators to conclude that sodium cromoglycate was not an effective agent in controlling asthma in very young infants.

Reviewer's Comments. This appeared to be a very well done investigation and employed twice the dose of sodium cromoglycate e.g. 40 mgm tid, than most of us would use. It certainly makes one wonder especially in view of Dr. Shirley Murphy's similar results with sodium cromoglycate in premature newborns and its failure to prevent BPD.

The use of inhaled corticosteroids to manage asthma in this young group of patients deserves such a carefully conducted study.
EFFECTS OF REDUCING OR DISCONTINUING INHALED BUDESONIDE IN PATIENTS WITH MILD ASTHMA
Authors: Chipps Bradley E.
Published: December 2021

Purpose of the Study. To determine the effect of decreasing the dose of inhaled steroid and delayed introduction of inhaled steroid on symptomatic control, pulmonary function, and bronchial hyperresponsiveness in new onset asthma.

Study Population. Thirty-seven asthmatics treated for 2 years with budesonide (1200 µg/day) were randomized to receive either placebo or budesonide (400 µg/day) in a double-blind continuation study for 1 additional year. Also 37 patients who had received inhaled terbutaline only during the initial 2 years of the study were crossed over and given budesonide 1200 µg/day for the subsequent year.

Methods. The drugs were delivered in a multi-dose powder inhaler. Histamine challenge studies were performed with six doubling step doses (1 to 32 mg/mL). A drop in forced expiratory volume in 1 second (FEV1) of 15% (PC15) was viewed as a positive test. Asthma symptom scores, home peak-flow recordings, and pulmonary function tests were recorded at regular intervals. If inadequate control was achieved with the study drugs, then sustained release theophylline was added and short courses (6 days) of oral corticosteroids were prescribed for acute exacerbations.

Findings. Pulmonary function studies and histamine challenge results did not change significantly at either budesonide dose. In the placebo group, the FEV1 decreased by 250 mL (P = .01) and PCI5 increased by 1.5 steps (P = .037). Likewise, asthma symptoms scores deteriorated as did morning peak flows in the group only treated with terbutaline. Early institution of inhaled steroid in newly diagnosed asthmatics lead to more rapid improvement in pulmonary function, decreased supplemental β-agonist usage, and improved symptom scores.
CONTROLLED TRIAL OF ORAL PREDNISONE IN THE EMERGENCY DEPARTMENT TREATMENT OF CHILDREN WITH ACUTE ASTHMA
Authors: Kettelhut Brett , Lee Napoleon , Kobayashi Roger H.
Published: December 2021

Initiation of oral prednisone in an emergency department setting reduced the hospitalization rate in a subset of children.
A META-ANALYSIS OF THE EFFECT OF ORAL AND INHALED CORTICOSTEROIDS ON GROWTH
Authors: Graft David F.
Published: December 2021

Meta-analytic integration supports the concern that there may be a small effect on growth with the use of oral corticosteroids (prednisone or other drugs). However, this technique also indicates that available studies of inhaled beclomethasone therapy do not show an association between its use and the adverse effect of diminished stature.
HIV INFECTION IS ACTIVE AND PROGRESSIVE IN LYMPHOID TISSUE DURING THE CLINICALLY LATENT STAGE OF DISEASE
Authors: Van Kerckhove Catherine , Liu Andrew
Published: December 2021

HIV virus is active in lymphoid tissues even during the asymptomatic stage of the disease. Therefore, a state of true microbiological latency does not exist during the course of HIV infection. The best way to fight HIV-1 disease, therefore, appears to be through prevention and early treatment.
FACTORS PREDICTIVE OF MATERNAL-FETAL TRANSMISSION OF HIV-1
Authors: Cotton Mark F.
Published: December 2021

Transmission of HIV from mother to infant is multifactorial. A significant drop in transmission seen with zidovudine was observed.
Epiglottitis and Haemophilus influenzae Immunization: The Pittsburgh Experience–A Five-Year Review
Authors: Valdepeña Hugo González , Wald Ellen R. , Rose Elizabeth , Ungkanont Kitirat , Casselbrant Margaretha L.
Published: December 2021

Objective. Current trends in the clinical presentation and management of children with epiglottitis at Children's Hospital of Pittsburgh were reviewed for the years 1988 to 1993.

Methodology. The medical records of all patients diagnosed as having epiglottitis between July 1988 and June 1993 at the Children's Hospital of Pittsburgh were reviewed. An additional telephone survey was conducted among the primary care physicians of those patients to collect information regarding administration of Haemophilus influenzae type b (HIB) vaccines.

Results. During the study period 28 children (age range, 11 months to 11 years, 10 months) were admitted with the diagnosis of epiglottitis. Cases declined remarkably in 1991. Fever, sore throat, and stridor were the usual symptoms. HIB was the most common cause of epiglottitis accounting for 21 cases. Candida albicans was recovered from the surface culture of the epiglottis in two patients. At least 11 children experienced vaccine failure: nine with polysaccharide vaccine and two with the conjugate vaccine for HIB.

Conclusion. Cases of epiglottitis have declined dramatically since licensure of HIB conjugate vaccines for use in early infancy. At least 52% of the reported cases represent vaccine failures with the purified polysaccharide vaccine.