bluuebunny/crossref_metadata_2025 huggingface dataset:
Is an Emergency Department Visit a Marker for Undervaccination and Missed Vaccination Opportunities Among Children Who Have Access to Primary Care?
Authors: Rodewald Lance E. , Szilagyi Peter G. , Humiston Sharon G. , Raubertas Richard F. , Roghmann Klaus J. , Doane Cynthia B. , Cove Lisa A. , Hall Caroline B.
Published: December 2021

The purpose of this study was to determine (1) whether preschool-age patients who utilize the emergency department (ED) are undervaccinated compared with patients having the same primary care provider and (2) whether reducing missed vaccination opportunities in the primary care office can potentially reduce the differences in undervaccination between the groups. This retrospective cohort study involved two groups: 583 ED patients, aged 4 to 48 months, who had primary care providers; and 583 control subjects randomly selected from primary care sites and matched according to date of birth and primary care site. The major outcome variable was the point prevalence of undervaccination, defined as more than 60 days past due for a vaccine at the time of the ED visit, and for control subjects, at the time of their matched patient's ED visit. Demographic variables, vaccination history, presence of chronic illness, and office utilization history were abstracted from office charts. The mean age of all patients was 20.0 months. Emergency department patients were more likely to be boys (61% vs 50%) and had more chronic illness, but did not differ racially from those in the control group. Primary care sites included a hospital-based clinic (n = 137), neighborhood health centers (n = 172), and private practices (n = 274). The undervaccination rates by primary provider type were for (1) hospital clinic ED patients 21.1%, control subjects 19.7%; (2) neighborhood health center ED patients 29.1%, control subjects 22.7%; and (3) private practice ED patients 26.6%, control subjects 14.9%. Overall, the odds ratio of ED patients' being undervaccinated compared with control subjects was 1.8 (95% confidence interval 1.3 to 2.5). This association was strongest for private practice patients (odds ratio 2.45, 95% confidence interval 1.5 to 4.2), but not significant for hospital clinic or neighborhood health center patients. Emergency department patients had previously missed more vaccination opportunities in the office than had control subjects (25% vs 16% of office visits). Taking advantage of missed vaccination opportunities would have greatly reduced undervaccination differences between ED patients and their controls. An ED visit is a marker for undervaccination, even for children who have primary care providers. These data support efforts to reach out to ED patients with interventions designed to increase their vaccination rates. Interventions in primary care offices, however, are likely to be the most effective.
Score for Neonatal Acute Physiology: A Physiologic Severity Index for Neonatal Intensive Care
Authors: Richardson Douglas K. , Gray James E. , McCormick Marie C. , Workman Kathryn , Goldmann Donald A.
Published: December 2021

The substantial variation in birth weight-adjusted mortality among neonatal intensive care units (NICUs) may reflect differences in population illness severity. Development of an illness severity measure is essential for comparisons of outcomes. The Score for Neonatal Acute Physiology (SNAP) was developed and validated prospectively on 1643 admissions (114 deaths) in three NICUs. SNAP scores the worst physiologic derangements in each organ system in the first 24 hours. SNAP showed little correlation with birth weight and was highly predictive of neonatal mortality even within narrow birth weight strata. It was capable of separating patients into groups with 2 to 20 times higher mortality risk. It also correlated highly with other indicators of severity including nursing workload (r = .59), therapeutic intensity (r = .78), physician estimates of mortality risk (r = .65), and length of stay (R2 = .59). SNAP is an important new tool for NICU research.
Saddened Not Amused
Authors: ASNES RUSSELL S. , GORDON SUSAN G.
Published: December 2021

To the Editor.—

The writers of this letter are two physicians who collectively have spent many years in the delivery of medical services to children and the teaching of medical students and pediatric house officers. Both of us were quite distressed on reading the article by D.S. Nelson (Pediatrics. 1992;89:1089-1090) about documenting humor in the pediatric emergency department.

We consider ourselves as having good senses of humor. We enjoy a good joke and a humorous story.
Amused Not Saddened
Authors: CHASTAIN DAVID O.
Published: December 2021

To the Editor.—

The article by Nelson concerning humor in the pediatric emergency department brings to mind several humorous situations in adolescent medicine.1

In adolescents the shift from concrete to abstract (or "formal") thought begins at about 12 years of age and usually is completed by 15 years of age.2 This delay in cognitive maturation is demonstrated by the adolescent who responds to the question, "Are you sexually active?" by pausing, looking puzzled, then responding, "I guess so... I used to just lay there, but now I move around more."
Intraoperative Anaphylaxis to Latex
Authors: PASQUARIELLO CAROLINE A. , LOWE DAVID A. , SCHWARTZ ROY E.
Published: December 2021

Since systemic reactions to latex were first described 5 years ago, an increasing number of these type I (IgE-mediated) allergic reactions have been reported in patients with long-term exposure to latex.1-6 The allergic manifestations range from localized erythema, urticaria, and pruritus of the exposed area to life-threatening angioedema and anaphylaxis. The reported cases of anaphylaxis have almost exclusively occurred intraoperatively. The children at greatest risk are those with myelomeningocele or congenital urologic abnormalities.7,8 These children have undergone multiple surgical procedures and/or repeated bladder catheterizations and radiologic procedures in which rubber catheters are used.

We describe two patients who experienced intraoperative anaphylaxis to latex.
Congenital Microgastria and Limb Reduction Defects
Authors: CUNNIFF CHRISTOPHER , WILLIAMSON-KRUSE LORI , OLNEY ANN HASKINS
Published: December 2021

In 1842 Robert1 reported the case of a girl with microgastria; hypoplastic left forearm, hand, and wrist; and asplenia. Since that time, six additional patients with a similar pattern of malformation have been described.2-7 The purposes of this report are to describe three additional cases of the microgastria-limb reduction complex which illustrate the clinical variability of this condition, to discuss overlap of this disorder with other malformation syndromes and associations, and to present evidence that suggests that the microgastria-limb reduction complex represents a developmental field defect.

CLINICAL REPORTS

Patient 1

Patient 1 was evaluated at age 1 month for bilateral absent thumbs.
Bilirubin and Brain Toxicity in Neonates: Dead but Won't Lie Down?
Authors: HANSEN THOR WILLY RUUD
Published: December 2021

To the Editor.—

During a meeting a few years ago, while discussing the issue of bilirubin and neurotoxicity, Dr Timos Valaes, a notable expert in the bilirubin field, suggested to me that "we may be flogging a dead horse." A couple of provocative articles recently published in Pediatrics seem to argue along the same lines.1,2 However, commentaries on those same articles, as well as the continued scientific interest in bilirubin neurotoxicity, suggest that the "animal" may still be standing.
Bilirubin and Brain Toxicity in Neonates: Dead but Won't Lie Down?
Authors: NEWMAN THOMAS B. , MAISELS M. JEFFREY
Published: December 2021

In Reply.—

We agree with Dr Hansen that much current management of hyperbilirubinemia is based on assumptions in need of scientific validation. This explains the considerable practice variation in different institutions that he described.

We disagree, however, that changing guidelines for management of hyperbilirubinemia is ethically unacceptable. An ethical obligation to treat jaundiced babies in any particular fashion must be based not on tradition, but on data that babies treated in that fashion do better than other babies.
Niacin Treatment of Hypercholesterolemia in Children
Authors: Colletti Richard B. , Roff Nancy K. , Neufeld Ellis J. , Baker Annette L. , Newburger Jane W. , McAuliffe Timothy L.
Published: December 2021

Objective. To determine the efficacy and adverse effects of niacin treatment of hypercholesterolemia in children.

Design. Retrospective review.

Setting. Two university hospital referral clinics.

Patients. All children who received single-drug niacin treatment for severe hypercholesterolemia between 1980 and 1991.

Results. Twenty-one children, aged 4 to 14 years, were treated with niacin, 500 to 2250 mg daily. Pretreatment total serum cholesterol value (mean ± SD) was 7.84 ± 1.14 mmol/L (303 ± 44 mg/dL), and low-density lipoprotein cholesterol value was 6.28 ± 1.16 mmol/L (243 ± 45 mg/dL). Niacin treatment in daily doses >1000 mg reduced total cholesterol by 23% and low-density lipoprotein cholesterol by 30% (P < .001) but had no effect on highdensity lipoprotein cholesterol and triglycerides. As in adults, reversible adverse effects were common, occurring in 16 (76%) of the 21 children. Six children (29%) had reversible dose-related elevations of serum aminotransferase levels. Niacin therapy was discontinued in 8 children (38%) because of flushing, abdominal pain, vomiting, headache, or elevated serum aminotransferase levels. Conclusions. This study suggests that although niacin treatment in children is efficacious, adverse effects are common. Until further study demonstrates long-term safety, niacin treatment should be reserved for the closely-supervised treatment of severe hypercholesterolemia by a lipid specialist.
Early Treatment of Premature Infants With Recombinant Human Erythropoietin
Authors: Messer Jean , Haddad Joseph , Donato Lionel , Astruc Dominique , Matis Jacqueline
Published: December 2021

Objectives. The specific objectives of this study were (1) to assess the safety and efficacy of recombinant human erythropoietin (rhEPO) in reducing postnatal hemoglobin decline in premature infants of less than 33 weeks' gestation, and thus reducing the need for transfusion; and (2) to determine the optimal dosage of rhEPO.

Materials and methods. Three groups of premature infants of less than 33 weeks' gestation were treated with rhEPO: group 1 (n = 10) received 300 U/kg per week; group 2 (n = 11), 600 U/kg per week; and group 3 (n = 10), 900 U/kg per week. These three groups were compared to a reference group of 20 infants of the same gestational age and birth weight. Treatment started on the 10th day of life and lasted 6 weeks. All infants were given oral iron and vitamin E supplements.

Results. Treated infants had significantly higher reticulocyte counts, and the effect was dose dependent (P = .009). Postnatal decline of hemoglobin and hematocrit was lessened in the treated groups; the percent of decrease of hemoglobin and hematocrit was significantly reduced in the treated infants at 35 days of age (P = .0025 and P = .0036, respectively). The need for blood transfusion was also reduced in the rhEPO-treated groups: 19% of treated vs 45% of reference infants received transfusions, and the treated infants received less blood. Serum iron and transferrin saturation percentage dropped significantly during the study and a dose-dependent relationship in treated infants was displayed, suggesting high iron consumption (P = .0008 and P = .006, respectively). No dose effect on hemoglobin level and the need for blood transfusion was found, possibly because of the higher degree of illness severity and iron consumption in groups 2 and 3. No side effects related to rhEPO therapy were observed.

Conclusions. It is concluded that rhEPO therapy is safe in premature babies when given in the three dosages used in this study; in addition, it enhances erythropoiesis and reduces the need for blood transfusions. rhEPO therapy seems more efficient when given in higher dosages; however, illness severity and iron consumption represent major limiting factors. Controlled, randomized studies are warranted to confirm these data and to determine precise modalities and indications of rhEPO therapy in premature infants.
CHINA: SEX IN THE OPEN
Authors: H. B.
Published: December 2021

The results of two nationwide surveys on "sex civilisation" conducted in 1989-90 in 15 large cities are to be published before the end of the year. The publication, On the Sex of the Chinese People, marks a turning point in Chinese attitudes to the discussion of sex. Until the 1980s, any discussion of the subject (except the minimum necessary for official family planning policy) was regarded as hooliganism or a sign of mental disturbance. The first course of public lectures on sex was held in Shanghai in 1985. Shanghai-based Prof Liu Dalin, author of the report, told the news agency Xinhua, "The age of being mysterious and innocent about sex has passed."

China has almost 1000 researchers working in areas such as sex medicine, sex psychology, sociology, and sexually transmitted diseases. Sex-education classes are held in more than a quarter of the higher education colleges, and over 87% of students have enrolled or would like to enrol. Sex education in middle schools, introduced as an experiment in 1988 in 7000 schools, is shortly to be extended to all schools.
Inhaled Nitric Oxide in the Management of a Premature Newborn With Severe Respiratory Distress and Pulmonary Hypertension
Authors: ABMAN STEVEN H. , KINSELLA JOHN P. , SCHAFFER MICHAEL S. , WILKENING RANDALL B.
Published: December 2021

Persistent pulmonary hypertension of the newborn (PPHN) is a clinical syndrome, characterized by sustained elevation of pulmonary vascular resistance (PVR) with right-to-left shunting across the ductus arteriosus and/or foramen ovale, causing severe hypoxemia. Although generally associated with diseases of term or near-term newborns, including group B streptococcal sepsis, PPHN has been described in preterm neonates as well. Recent echocardiographic studies have demonstrated increased PVR in preterm neonates with hyaline membrane disease (HMD), which correlated with disease severity and mortality. Severe HMD was associated with lower aortopulmonary pressure gradients and left pulmonary artery blood flow velocities during the first 72 hours after birth, suggesting that high PVR contributes to the mortality of respiratory distress of premature neonates.
In Reply: International Statistics—Incomparable
Authors: HOWELL EMBRY M. , VERT PAUL
Published: December 2021

Dr Sepkowitz makes several correct points about the French vital registration system that leads to incomparability with Michigan vital statistics.

• Definitions of fetal deaths are dissimilar. The French registration system ignores fetal deaths at less than 28 weeks gestation.

• In France, it is the responsibility of parents to register births.

• France has had a unique category of "deaths before registration."

However, he is incorrect in suggesting that these differences affected the results reported in our article. It is precisely for these reasons that we did not use data from the French vital registration system. Instead we used data that were carefully collected during a 1-year period in Lorraine's hospitals under the direction of the French Health Ministry that directly controls French hospitals.
HOSPITAL EXECUTIVES' PAY ROSE SHARPLY IN A DECADE
Authors: L. J. F.
Published: December 2021

WASHINGTON, Sept. 29—The rise in nonprofit hospital executives' compensation in the 1980's was one of the fastest-growing components of the overall rise in medical costs, with the earnings of a few executives at the most prestigious institutions approaching or exceeding $1 million.

Although executive pay represents a small fraction of total revenues in any hospital, it is a matter of particular interest to Internal Revenue Service auditors. Special audits of about 20 hospitals nationwide are under way, examining if these educational and charitable institutions, in their zeal to compete in the high-stakes health-care field, are straying from the ground rules governing tax-exempt status.

Among other things, these rules prohibit nonprofit organizations from providing "excessive" benefits to private individuals, a definition open to a range of interpretations. IRS officials said that executive salaries are one of the issues under scrutiny in their audits...

While salaries for top hospital executives around the nation tend to run in the $200,000 range, with compensation routinely $100,00 to $200,000 higher for doctors serving as chief executive officers, a few hospitals pay at double or triple the base rates...

[The] president and chief executive officer of New York City's Memorial Sloan-Kettering Cancer Center made more than $1 million in total compensation in both 1990 and 1991 . A 1988 "signing bonus," . . . brought his total compensation for that year to $2.2 million. The center employs 5,600 and has a $700 million budget for 1992.

[The] head of Brigham and Women's Hospital in Boston made $872,628 in total compensation in 1991 . The teaching hospital, affiliated with Harvard Medical School, employs about 8,000 people.
Hepatitis B Immunization in Infants of Hepatitis B Surface Antigen-Negative Mothers
Authors: CHIRICO GAETANO , BELLONI CESARE , GASPARONI ANTONELLA , CERBO ROSA MARIA , RONDINI GIORGIO , KLERSY CATHERINE , ORSOLINI PAOLO , FILICE GAETANO
Published: December 2021

The American Academy of Pediatrics (AAP) Committee on Infectious Diseases and the Immunization Practices Advisory Committee of the Centers for Disease Control have recently pointed out that the selective strategy of immunization against hepatitis B virus (HBV) of high-risk populations has not resulted in the limitation of the diffusion of the disease. In fact, in spite of vaccine availability for more than 10 years, about 200 000 to 300 000 new cases of infection occur in the United States each year. Therefore, the AAP recommended the "universal hepatitis B immunization" strategy as a means to control the disease.1,2

In Italy, where about 400 000 new cases of infection are expected each year, the vaccination has been extended to all newborns, regardless of mother's serologic status (and, for the first 12 years, to all 12-year-old adolescents), with a law promulgated in May 1991.
Clinical Features of Infants With Primary Human Herpesvirus 6 Infection (Exanthem Subitum, Roseola Infantum)
Authors: Asano Yoshizo , Yoshikawa Tetsushi , Suga Sadao , Kobayashi Ikuko , Nakashima Toshihiko , Yazaki Takehiko , Kajita Yuji , Ozaki Takao
Published: December 2021

Objective. To clarify clinical features of patients with primary human herpesvirus 6 (HHV-6) infection (roseola infantum, exanthem subitum) in a large-scale study.

Subjects and methods. Clinical signs and symptoms were analyzed in 176 infants in whom exanthem subitum was initially suspected and primary HHV-6 infection was later confirmed. The infection was proved by isolation of the virus from blood, a significant increase in the neutralizing antibody titers to the virus, or both.

Results. The primary HHV-6 infection, which occurred throughout the year, was observed in 94 boys and 82 girls (mean age, 7.3 months). Fever developed in 98% (mean maximum fever, 39.4°C) and lasted for 4.1 days. Macular or papular rashes appeared in 98%, on face, trunk, or both, mostly at the time of subsidence of the fever, and lasted for 3.8 days. Other clinical manifestations occurred as follows: mild diarrhea in 68%, edematous eyelids in 30%, erythematous papules in the pharynx in 65%, cough in 50%, and mild cervical lymph node swelling in 31%. Twenty-six percent had bulging of the anterior fontanelle and 8% had convulsions.

Conclusions. Clinical features of patients with virologically confirmed exanthem subitum were comparable with those described before discovery of HHV-6.
CALPERS TELLS 18 HEALTH-CARE PROVIDERS IT EXPECTS A 5% ROLLBACK IN PREMIUMS
Authors: L. J. F.
Published: December 2021

In it most aggressive swipe at health-care costs to date, the huge California Public Employees' Retirement System served notice that it expects health-care providers to agree to a 5% rollback in health-care premiums for 900,000 public employee families ...

Calpers, which manages one of the country's largest groups of insured individuals and is often cited as a model of health-care reform, told 18 managed-care companies that it expects the 5% rollback to be effective in the 1994-95 contract year, which begins August 1 ...

Providers expressed surprise and muted alarm at the depth of the cutback proposed ...

The 5% target was based on numerous studies, not only of individual HMO fiscal data, but also on Rand Corp. studies showing the persistence of waste and overutilization in health care which documented excessive Caesarean deliveries, overuse of magnetic resonance imaging scans, overprescribing of drugs, and performance of unnecessary surgery when less invasive procedures would suffice.
Smoking and Health in Substance-Abusing Adolescents: A Two-Year Follow-up
Authors: Myers Mark G. , Brown Sandra A.
Published: December 2021

Objective. To examine the prevalence and persistence of cigarette smoking along with health outcomes in a clinical sample of substance-abusing adolescents.

Design. This is a 2-year prospective case series study.

Setting. Subjects were recruited from two private, hospital-based inpatient adolescent substance abuse treatment facilities.

Participants. A consecutive sample of 166 adolescents, ages 12 to 18, meeting Diagnostic and Statistical Manual of Mental Disorders (3rd ed, revised) criteria for substance abuse participated in the present investigation. Of the original sample, 154 and 144 were interviewed 12 and 24 months after discharge, respectively.

Measurement and results. Information regarding cigarette smoking, drug and alcohol use, and respiratory problems was based on self-report by the adolescents and was corroborated by parent interview. The prevalence of smoking in this sample of teens immediately before treatment was 85%. Sixty-one percent of the sample smoked ½ pack or more/day and 75% were daily smokers. Although prevalence (74 and 77%) and average daily cigarette consumption (11.1 and 10.7 cigarettes daily) decreased at 12 and 24 months after treatment, rates remained very high. Teens reporting posttreatment respiratory problems smoked more, and heavier smokers at the time of treatment were more likely to report respiratory problems at follow-up than lighter smokers.

Conclusions. Substance-abusing teens smoke at rates far and above those of the general adolescent population. Further, these teens appear at increased risk for negative health consequences regardless of posttreatment drug and alcohol use. These findings highlight the importance of preventing adolescent cigarette smoking by substance abuse treatment programs.
Letter to the Editor
Authors: McIntire Sara C. , Rubenstein Ronald C. , Gartner J. Carlton , Gilboa Nisan , Ellis Demetrius
Published: December 2021

The patient described by Wattad et al is quite similar to the two children we describe.1 Once again the striking features are acute flank pain and nonoliguric renal dysfunction. The renal biopsy demonstrates mild interstitial nephritis. We believe that knowledge of the association of this clinical syndrome with nonsteroidal anti-inflammatory drug use will make renal biopsy (and its potential complications) unnecessary in evaluating future cases. We strongly suspect that this condition is much more common than previously recognized.
Letter to the Editor
Authors: Carter Brian S.
Published: December 2021

It is important to know the data that Wiswell and associates have compiled and reported concerning circumcision in children after the neonatal period.1 Of interest would be whether or not a significant percentage of parents who sought late circumcision for their children might have chosen neonatal circumcision with more adequate counselling, or perhaps sought the procedure in early infancy if such an option existed? It appears that only 20% of infants received late circumcision during the first year of life.
Letter to the Editor
Authors: Harrison Helen
Published: December 2021

We appreciate Dr Cunningham's candor in describing a situation some of us have experienced first-hand.

A disinclination to be the bearer (or recipient) of bad news lies behind many communication failures in the neonatal intensive care unit and beyond. It is no excuse for withholding the truth from families.

Some parents do react with anger to bad news about their child, at least initially. Others, however, are relieved to have their own perceptions confirmed and to have a diagnosis that can serve as the basis for action to help their child.
Measles Vaccine Immunogenicity in 6- Versus 15-Month-Old Infants Born to Mothers in the Measles Vaccine Era
Authors: Johnson Candice E. , Whitwell Judy , Kumar Mary L. , Nalin David R. , Chui Linda W. , Marusyk Raymond G.
Published: December 2021

Hypothesis. The low titer of measles antibody in infants of mothers with vaccine-induced immunity may allow immunization against measles before 15 months of age.

Methods. Six- and 15-month-old infants born to mothers ≤ 30 years of age with no history of measles were recruited. Infants enrolled at 6 months of age were immunized with monovalent measles vaccine (Attenuvax), and maternal serum and infant pre- and postvaccination sera were obtained. Those enrolled for primary vaccination at 15 months of age received either Attenuvax (N = 12) or M-M-RII (N = 3). Six-month-old infants were revaccinated with M-M-RII at 15 months of age; pre- and postrevaccination sera were again obtained. Three antibody assays were used: a measles neutralizing assay (NT) and two enzyme immunoassays (EIA) for measles IgG and measles IgM.

Results. Among primary vaccinees, 14 of 19 infants aged 6 months (74%) developed NT antibody, as did 15 of 15 infants aged 15 months (100%). The reciprocal geometric mean titer of 6-month-old seroresponders was 23.3, significantly lower than that of the 15-month-old primary vaccinees (87.7, P < .001). Primary seroconversion rates by EIA were 53% for 6-month-old infants and 100% for those aged 15 months. Revaccination of infants who had received Attenuvax at 6 months of age resulted in 100% NT positivity; the geometric mean titer rose to equal that of the group given primary immunization at 15 months of age. Measles IgM antibody was detected in 10 of 14 infants tested 1 month after primary vaccination at 15 months, but was not detected in any of the revaccinated infants after the second dose at 15 months of age (P < .001).

Conclusions. 1) Immunization with measles vaccine in infants born to vaccine-immune mothers at 6 months of age induced NT antibody in 74% of infants. 2) Revaccination of prior 6-month-old vaccinees at 15 months resulted in antibody titers equivalent to 15-month-old vaccinees. 3) Lack of an IgM response following revaccination suggests that even seronegative infants may be primed to respond on re-exposure to measles.
Senior-Loken Syndrome: Revisited
Authors: Warady Bradley A. , Cibis Gerhard , Alon Uri , Blowey Douglas , Hellerstein Stanley
Published: December 2021

The combination of familial juvenile nephronophthisis (FJN) and congenital amaurosis of Leber, the so called Senior-Loken Syndrome, was first described by Senior et al in 1961.1 Despite recognition of the syndrome for > 30 years, its occurrence is relatively rare and the basis for the oculorenal association remains unresolved. Our recent experience with two patients who had end-stage renal disease (ESRD) as a manifestation of the syndrome prompted this review.

CASE HISTORIES

A.M. is an 11-year-old girl who complained of generalized fatigue over the previous 3 weeks. The patient had been diagnosed with Leber's amaurosis at 3 months of age.
WHAT DO HEALTH CARE PROFESSIONALS KNOW ABOUT CHILDHOOD ASTHMA?
Authors: Joos Than H.
Published: December 2021

Purpose of the Study. Salbutamol (albuterol) metered dose inhalers are a nonprescription, over-the-counter medication in Australia. In some instances, therefore, the only health care professional to advise asthmatics is the pharmacist. The present study was performed to assess the asthma knowledge base of pharmacists, general practitioners, and pediatric nurses in a given geographic area.

Methods. A questionnaire that was developed and tested with medical students and parents of asthmatics was mailed to the above groups of health care professionals in the New Castle region of New South Wales, Australia.

Results. An overall return rate of 50% was obtained. The following areas of significant knowledge deficiencies were noted:

1) Pharmacists—Fifty-six percent were unaware of the three cardinal symptoms of asthma: cough, wheeze, and breathlessness, 52% were unaware that asthma often worsens at night, and 57% did not know that viral infections were common triggers of asthma.

2) General Practitioners—Thirty-four percent believed childhood asthma damages the heart, 28% were unable to name three treatments useful in an acute attack, and 18% could not name two asthma preventative drugs.

3) Pediatric nurses—Fifty percent were uninformed regarding the need to seek medical care if nebulizer treatments were required more frequently than every two hours, 40% said inhaled medicines caused more side effects than their oral counter parts, and 40% thought auscultation was the best way to assess asthma.

Reviewer's Comments. How would we in America compare, if asked to participate in such an exercise? I would let the reader decide, but in general we need to enlarge our educational programs.
THE $4.3 BILLION MISTAKE
Authors: L. J. F.
Published: December 2021

Three recent epidemiological studies of purported links between breast implants and a variety of ailments, notably the skin hardening disease scleroderma, have concluded that the linkage simply cannot be established.

Gee, that's nice to know. Better late than never. Too bad, though, that in our era the scientific method can't compete anymore with lawyers marauding after some $1 billion in contingency fees, politically correct mind-sets in the media, or Dr. Kessler's Food and Drug Administration.

It's too bad, because as a result of the atmosphere of fright created by this triumvirate, nearly all companies withdrew from the silicone breast-implant market. Mastectomy patients, past and future, now face a destroyed market for silicone implants.

It has to be understood that these plaintiffs' lawyers have a huge economic incentive in the outcome of such cases because they get an enormous percentage cut of any settlement. It is in their economic interest to make the stories of diseases related to silicone implants as lurid and horrible as possible, because it drives deep-pockets defendants toward settlements like the $4.3 billion pot set up by Dow Corning, Bristol-Myers, Baxter Labs, 3M, and others in this case. Only about 22 lawyers will be divvying up most of the $1 billion in contingency fees.
Depressive Symptoms and Work Role Satisfaction in Mothers of Toddlers
Authors: Olson Ardis L. , DiBrigida Lisa A.
Published: December 2021

Objective. To determine the incidence of depressive symptoms in mothers of toddlers in community pediatric practice. The interaction of employment and work role satisfaction with depressive symptoms was also investigated.

Subjects and methods. Depression screening measures were completed by 233 mothers of toddlers (aged 12 to 24 months) at health supervision visits in two community pediatric practices in New Hampshire. Depression was evaluated with a depressive symptom screening inventory modified by Barrett, Oxman, and Gerber from the Hopkins Symptom Checklist for use in primary care population. Data were obtained on parents' socioeconomic variables, hours worked, and whether the mother was satisfied with her current role of being employed or not employed.

Results. Depressive symptoms were present in 42% of mothers. Rates of depressive symptoms were similar in employment groups but varied significantly with work role satisfaction. When both employment and satisfaction were considered, mothers who were dissatisfied were 3.7 times more likely to be depressed. After controlling for work role satisfaction, mothers working part time were half as likely to be depressed as mothers working full time and not employed.

Conclusion. Depressive symptoms are a major problem for mothers of toddlers in middle class pediatric practice. Work role satisfaction and employment status together are related to depressive symptoms.
Boilerbaisse: An Outbreak of Methemoglobinemia in New Jersey in 1992
Authors: Askew George L. , Sosin Daniel M. , Finelli Lyn , Genese Carol A. , Sorhage Faye E. , Spitalny Kenneth C.
Published: December 2021

Background. On October 20, 1992, > 40 children from one elementary school visited the school nurse due to the acute onset of blue lips and hands, vomiting, and headache during and after the school lunch periods. Forty-nine children were seen by physicians that day and 14 were hospitalized. Laboratory analysis revealed methemoglobinemia in many of the children. All recovered in 36 hours.

Objective. A case-control study was supplemented by environmental and laboratory investigations to determine the outbreak source.

Methods. Cases were selected based on the laboratory diagnosis of methemoglobinemia (methemoglobin level > 2%). Children whose methemoglobin levels were missing or < 2% were excluded from analysis. Controls were obtained by selecting every third name from a school roster. The parents of 29 students who met the case definition and 52 controls were interviewed.

Results. All 29 cases and 33% (17/52) of the controls ate soup during the school lunch (odds ratio undefined, lower 95% confidence limit 16.1). Two pots of soup were prepared from ready-to-serve cans, which were diluted with water and enriched with a commercially prepared flavor enhancer. The school's boiler, dormant during the previous 5 months, was restarted on the morning of the outbreak. The boiler also served as a tankless hot water heater. Laboratory analysis of the soup identified abnormally high quantities of nitrite (459 ppm) and sodium metaborate, major components of the boiler water treatment solution. Undiluted soup from the same lot had 2.0 ppm nitrites; the flavor enhancer had 2.2 ppm nitrites. Nitrites were present in the hot potable water system (4 to 10 ppm) and absent in the cold potable water system.

Conclusions. This outbreak of methemoglobinemia due to nitrite poisoning was traced to soup contaminated by nitrites in a boiler additive. Nitrites are ubiquitous and potentially hazardous inorganic ions. Extreme caution should be used when the possibility for toxic human exposure to nitrites exists.
Letter to the Editor
Authors: Harvey Birt
Published: December 2021

Needleman and other distinguished investigators of lead toxicity raise three issues.

1. Whether lead is a neurotoxin. Here there is full agreement. As I stated in my editorial, "Lead is a poison, and the less of it in the bodies of growing children the better."1 Adverse effects in young children possibly may occur at blood lead (BPb) levels <10 µg/dL However, neither the epidemiologic studies cited by Needleman and colleagues nor any references I could find demonstrate that BPb <20 µg/dL at age I year causes a clinically important decrease in intelligence or an increase in neurobehavioral problems by the time a child enters school.
MORE SKATERS, MORE INJURIES
Authors: L. J. F.
Published: December 2021

The Product Safety Commission forecasts 83 000 emergency room cases this year from skating injuries, more than double last year's figure. Sixty percent will be children under age 15. Wrist injuries are the most common, followed by lower arm, leg, and head injuries. What makes in-line skating (or Rollerblading, from the name of a popular brand) dangerous is failure to wear protective gear, lack of instruction and possibly what the commission calls "high-risk behavior," or what daredevils call hot-dogging.

Most people are being injured because the sport has become so popular—l2 million participants last year compared with 3.5 million participants in 1990. There are also a huge number of beginners.
Caring for Gravely Ill Children
Authors: Fleischman Alan R. , Nolan Kathleen , Dubler Nancy N. , Epstein Michael F. , Gerben Mary Ann , Jellinek Michael S. , Litt Iris F. , Miles Margaret Shandor , Oppenheimer Sonya , Shaw Anthony , van Eys Jan , Vaughan Victor C.
Published: December 2021

Background. Much has been written about the care of the hopelessly ill adult, but there is little guidance for pediatric health care professionals in the management of children who are critically or terminally ill.

Methods. Through a 3-day meeting in Tarrytown, NY, attended by a group of pediatricians and others directly involved in these issues, a principled approach was developed for the treatment of, and health care decision-making for, children who are gravely ill.

Results. The group agreed that the needs and interests of the child must be the central focus of any treatment plan and that the child should be involved to as great extent possible, consistent with developmental maturity, in the decision-making process. Quality of future life should be viewed as being relevant in all decisions. Parents are believed to be the natural guardians of children and ought to have great latitude in making decisions for them. However, parental discretion is not absolute and professionals must maintain an independent obligation to protect the child's interests.

Conclusions. Decision-making should be collaborative among patient, parents, and professionals. When conflict arises, consultation and ethics committees may assist in resolution. When cure or restoration of function is no longer possible, or reasonable, promotion of comfort becomes the primary goal of management. Optimal use of pain medication and compassionate concern for the physical, psychological, and spiritual well-being of the child and family should be the primary focus of the professionals caring for the dying child.
Gun Violence Among Youth and the Pediatrician's Role in Primary Prevention
Authors: Webster Daniel W. , Wilson Modena E. H.
Published: December 2021

Adolescence is a developmental stage characterized by high rates of violent behavior. Increasingly, violent injury is involving preadolescent children. Evidence suggests that the availability of guns increases the lethality of violent acts. Because guns are ubiquitous in the United States and integral to the current epidemic of youth violence, pediatricians should participate in primary prevention of firearm injuries. Efforts should begin long before children reach adolescence. Pediatricians should: (1) Encourage parents to remove guns from the home, or at a minimum to keep guns unloaded and locked up; (2) Advise parents to limit viewing of gun violence in the media, and playing with toy guns and video games that involve shooting (3) Be alert for early indicators of aggressive behavior; and (4) Become outspoken advocates for laws that restrict gun availability.
OUT OF THE MOUTHS OF SEPTUAGENARIANS..
Authors: Student
Published: December 2021

Someone asked Bruce Bliven, then in his seventies, what it felt like to be an old man. Bliven retorted, "I don't feel like an old man. I feel like a young man with something the matter with him."
Pulmonary Hemorrhage Risk in Infants With a Clinically Diagnosed Patent Ductus Arteriosus: A Retrospective Cohort Study
Authors: Garland Jeffery , Buck Rosanne , Weinberg Michelle
Published: December 2021

Objective. To determine if an early, dinically detectable patent ductus arteriosus (FDA) was associated with pulmonary hemorrhage (PH) in infants who received rescue artificial surfactant therapy.

Methods. This retrospective cohort study of 233 low birth weight infants (≤ 1700 g) who received artificial surfactant therapy for respiratory distress syndrome compared antenatal and postnatal characteristics of infants with PH and without PH. Pulmonary hemorrhage was defined by an onset of bright red blood from the endotracheal tube in quantities that resulted in increased ventilatory support and a new infiltrate on a chest radiograph.

Results. Pulmonary hemorrhage occurred in 6% (15/233) of the infants. Thirty-three percent (5/15) of the infants with PH died within 14 days of the hemorrhage. Of the 15 PH, 73% occurred within 48 hours of the first surfactant dose. Pulmonary hemorrhage was more common in male infants and infants of mothers who received antibiotic therapy during labor (P ≤ .04). Infants with PH received surfactant earlier than those without PH (P = .04). Nursery events or therapies occurring following surfactant therapy that were associated with PH included: little improvement in ventilatory efficiency index (P = .01), dopamine infusion (P = .04), and the presence of a clinically detectable PDA before, or at the time of, the PH [60% (9/15) vs 33% (71/217), P = .03]. After adjusting for severity of illness before surfactant therapy, risk of PH remained greater in infants who developed symptoms of a PDA. Dopamine support appeared to modify the association between PDA and PH.

Conclusions. In this retrospective cohort study, pulmonary hemorrhage was associated with the presence of a clinically detectable patent ductus arteriosus before, or at the time of, pulmonary hemorrhage.
Administration of the Third Dose of Oral Poliomyelitis Vaccine at 6 to 18 Months of Age
Authors:   Committee on Infectious Diseases
Published: December 2021

This statement describes a modification of the recommended routine schedule for administering trivalent oral poliomyelitis vaccine (OPV). The American Academy of Pediatrics previously has recommended that healthy children receive a three-dose primary series of OPV at 2, 4, and 15 to 18 months of age and a fourth dose at the time of school entry (4 to 6 years of age).1 Available data indicate that the response rates to the third dose of OPV administered at 6 months of age are as good as the rates following administration of this dose at 15 to 18 months of age. Completion of the three-dose primary series at an earlier age will help health care providers induce immunity against poliomyelitis at an early age.

Although wild type poliomyelitis has not caused disease in the United States for many years, the virus remains prevalent in many countries. Continued introduction of the virus into the United States by travelers could result in transmission and disease if high levels of immunity are not maintained in preschool age children. For example, wild type poliovirus type 3 was recently introduced into Canada by a religious sect that did not believe in immunization.2 The virus was probably imported from the Netherlands, where a small epidemic of poliomyelitis occurred in members of the same sect in 1992 and 1993.3

SERUM ANTIBODY RESPONSE FOLLOWING OPV ADMINISTRATION

After two doses of OPV are administered at 2 and 4 months of age, 89 to 100% of children vaccinated in the United States have evidence of humoral immunity to poliomyelitis types 1 and 3, and 99 to 100% have immunity to type 2 (Table).
PARENTAL PSYCHOPATHOLOGY AND CHILDREN'S ADJUSTMENT TO LEUKEMIA
Authors: Brown Ronald T. , Kaslow Nadine J. , Madan-Swain Avi , Doepke Karla J. , Sexson Sandra B. , Hill Lauren J.
Published: December 2021

Objective: The primary purpose of this study was to examine the relationship between parental psychopathology and psychosocial functioning of children in whom acute lymphocytic leukemia (ALL) has been diagnosed. Method: The sample consisted of 61 mother-child dyads. Twenty-one (34%) mothers met DSM-III-R criteria for at least one psychiatric disorder based on a Structured Clinical Interview for Diagnosis (SCID). Results: Findings revealed that compared with children whose mothers did not meet DSM-III-R criteria for a psychiatric disorder, children with mothers who evidenced a psychiatric disorder self-reported more anxiety and a maladaptive attributional style and were reported by their mothers as evidencing more depression and a range of internalizing behavioral symptoms. Conclusions: Although our earlier research suggested that ALL children show relatively few symptoms of psychopathology, the present report reveals high rates of psychiatric difficulties in the mothers of ALL youth. These findings and their implications are discussed within a model that incorporates behavioral pediatrics and developmental psychopathology.
Environmental Quality of Child Day-Care Facilities: An Architect's Point of View
Authors: Passantino Richard J. , Bavier Robert N.
Published: December 2021

National statistics clearly point to a continuing rise in the demand for child day-care and preschool facilities, so it is essential that we provide children with a place to go during the day where they can be cared for, learn, and be protected from environmental hazards while being given the greatest benefit of high-quality and safe buildings. Through awareness of environmental hazards and integration of this awareness into their designs, architects can greatly contribute to such safe and stimulating environments.9
Financing Child Care: Public- and Private-Sector Approaches
Authors: Eichman Caroline
Published: December 2021

Finding high-quality, affordable child care is of paramount concern for millions of American families. Child-care providers, concerned about the high costs associated with providing a quality service, are unable to access, through the traditional market mechanisms, the funding they need to support their start-up and operating costs. For providers to offer a high quality service—to hire trained professional staff, maintain group sizes and staff-to-child ratios at NAEYC-recommended standards, provide a curriculum that early childhood professionals view as developmentally appropriate, and provide a healthy and safe environment for children—additional resources are needed.

By properly targeting their resources, states can be an important catalyst for private sector initiatives. By designing programs that leverage taxpayer dollars with private investment, states can create new cost-effective approaches. Groups within the private sector such as employers, real-estate developers, lending institutions, and community development corporations are finding that investing in child care can be a good business decision.
Regulation and Guidelines Toward a Healthy Child-Care Setting
Authors: Koch Pauline D.
Published: December 2021

States can make a strong investment in creating a healthy child-care setting by developing coordinated career development systems for child-care practitioners. The licensing agency must be involved and is the logical agency to administer the system. Through a project entitled "Delaware First. Again," Delaware became the first in the country to develop a plan for a comprehensive, coordinated statewide early care and education career system. The project is directed by the Office of Child Care Licensing with consultation from Gwen Morgan and Joan Costley of Wheelock College and Nancy Brown of North Carolina State University.

The focus on training and career development will prove to be a cost efficient and effective method for states to substantially improve the health and safety of children in child care and will provide advocacy for stronger licensing requirements. Long-term improvement will only accrue with corresponding substantial improvement in the wages and other employee benefits for the people who work with our children. In summary, regulation and guidelines can play an increasingly larger role in creating a healthy child-care setting. There is much to be done at the national, state, and local levels to accomplish this goal. With continued strong advocacy and a coordinated effort, the goal can be met.