bluuebunny/crossref_metadata_2025 huggingface dataset:
Posterior Scleritis and Its Association with HLA B27 Haplotype
Authors: Anshu Arundhati , Chee Soon Phaik
Published: June 2007

Background: Posterior scleritis is most commonly idiopathic but is also found in association with systemic disorders like rheumatoid arthritis. HLA B27 spondyloarthropathy manifests itself mainly in the form of anterior uveitis and anterior scleritis. Posterior scleritis has not been previously reported in patients with HLA B27 haplotype. We document the likely association between posterior scleritis and HLA B27 haplotype in a series of 5 patients who presented to the Ocular Inflammation and Immunology Services of the Singapore National Eye Centre. Methods: Retrospective observational case series. The medical records and ultrasound B scans of 5 patients with a diagnosis of posterior scleritis were reviewed. Results: The medical records of 5 patients (4 Chinese and 1 Malay) in the age range of 22–64 years were reviewed. All had unilateral disease (4 in the left eye and 1 in the right eye) at presentation. The most common presenting symptoms were pain (5) and blurring of vision (5); diplopia and proptosis was present in 2 patients. Two patients had anterior scleritis and all had an associated anterior uveitis. Posterior segment findings included optic disc edema (5), macular edema (5), choroidal folds (3), exudative retinal detachment (2) and choroidal effusion (1). All patients had a thickened sclera on serial ultrasound B scan. 2 patients had joint involvement preceding ocular signs and symptoms and were diagnosed to have ankylosing spondylitis. HLAB27 was positive in all our patients. Systemic workup for other diseases was negative. The ocular inflammation responded to a varying combination of topical, periocular and systemic steroids. One of them developed a recurrence of posterior scleritis which resolved with oral steroids. Visual outcome was satisfactory in all but 1 patient who had retinal pigment epithelium atrophy at the macula. Conclusion: Although posterior scleritis has been reported in association with ankylosing spondylitis, it is not clear whether it is the HLAB27 haplotype that is associated with posterior scleritis or ankylosing spondylitis. All our patients were HLAB27 positive but 2 of them did not have an underlying spondyloarthropathy. This suggests the possible association of posterior scleritis with HLAB27 haplotype.
Exacerbation of Pityriasis Rubra Pilaris under Efalizumab Therapy
Authors: Klein A. , Szeimies R.-M. , Landthaler M. , Karrer S.
Published: June 2007

A 60-year-old woman, diagnosed as having psoriasis vulgaris in 2004 and unresponsive to standard therapies, received weekly subcutaneous injections with efalizumab. Within 9 weeks of treatment a massive aggravation of skin lesions occurred with widespread orange-tinged erythroderma, islands of normal skin on the back and the inner side of the forearms and palmoplantar hyperkeratosis. A biopsy confirmed the clinical diagnosis of pityriasis rubra pilaris. After discontinuation of efalizumab and treatment with oral corticosteroids, acitretin (30 mg/day) and PUVA therapy, the skin lesions continuously improved. Efalizumab, a fully humanized monoclonal antibody against CD11a, inhibits various T cell processes important in the pathogenesis of psoriasis. Efalizumab has been approved for the treatment of moderate to severe psoriasis, but there are no reports in the literature on the use of efalizumab for pityriasis rubra pilaris.
Glycosylation at the Fetomaternal Interface in Hemomonochorial Placentae from Five Widely Separated Species of Mammal: Is There Evidence for Convergent Evolution?
Authors: Jones Carolyn J.P. , Carter Anthony M. , Aplin John D. , Enders Allen C.
Published: June 2007

Hemomonochorial placentation occurs in diverse species. We have examined placental glycosylation in five widely separated mammals with this type of placentation – lesser hedgehog tenrec (Echinops telfairi), spotted hyena (Crocuta crocuta), nine-banded armadillo (Dasypus novemcinctus), human (Homo sapiens) and guinea pig (Cavia porcellus) – in order to assess whether evolutionary convergence to the hemomonochorial state is accompanied by a similar convergence of glycan expression. Placentae from 2 E. telfairi, 3 C. crocuta, 1 D. novemcinctus, 4 womenand 1 C. porcellus were fixed and processed into epoxy resin. Binding of twenty-three lectins was assessed using a semiquantitative ranking system. The trophoblast apical/microvillous membrane of all five species showed marked similarities in glycosylation. In the N-linked series, there were abundant bi/tri-antennary complex chains, while the non-bisected variants were much scarcer. All species had plentiful N-acetyl lactosamine sequences; at chain termini, binding to Galβ1,4GlcNAc and Galβ1,3GalNAc sequences was greatly enhanced after neuraminidase treatment. In all species, terminal NeuNAcα2,3 residues were detected. The tenrec had unusually abundant terminal N-acetyl galactosamine. The basal plasma membrane/basal lamina showed glycosylation patterns distinct from the microvillous membrane in each case, indicating chemical diversity of the two opposite faces of trophoblast. Similar classes of glycan at the hemochorial interface suggest conservation of function. The observed lectin binding patterns suggest broad similarities of glycosylation that may have arisen by convergent evolution.
Cognitive and Neurophysiological Outcome of Cardiac Arrest Survivors Treated With Therapeutic Hypothermia
Authors: Tiainen Marjaana , Poutiainen Erja , Kovala Tero , Takkunen Olli , Häppölä Olli , Roine Risto O.
Published: June 2007

Background and Purpose—

Cognitive deficits are common in survivors of cardiac arrest (CA). The aim of this study was to examine the effect of therapeutic hypothermia after CA on cognitive functioning and neurophysiological outcome.

Methods—

A cohort of 70 consecutive adult patients resuscitated from out-of-hospital ventricular fibrillation CA were randomly assigned to therapeutic hypothermia of 33°C for 24 hours accomplished by external cooling or normothermia. Neuropsychological examination was performed to 45 of the 47 conscious survivors of CA (27 in hypothermia and 18 in normothermia group) 3 months after the incident. Quantitative electroencephalography (Q-EEG) and auditory P300 event-related potentials were studied on 42 patients at the same time point.

Results—

There were no differences between the 2 treatment groups in demographic variables, depression, or delays related to the resuscitation. No differences were found in any of the cognitive functions between the 2 groups. 67% of patients in hypothermia and 44% patients in normothermia group were cognitively intact or had only very mild impairment. Severe cognitive deficits were found in 15% and 28% of patients, respectively. All Q-EEG parameters were better in the hypothermia-treated group, but the differences did not reach statistical significance. The amplitude of P300 potential was significantly higher in hypothermia-reated group.

Conclusions—

The use of therapeutic hypothermia was not associated with cognitive decline or neurophysiological deficits after out-of-hospital CA.
Acute Myocardial Infarction in a Patient with Essential Thrombocythemia Who Underwent Successful Stenting
Authors: Watanabe Tomonori , Fujinaga Hiroyuki , Ikeda Yasumasa , Higashi Teruo , Murakami Masaru , Kawahara Keiji , Hayashi Ikuro , Niki Toshiharu , Shigekiyo Toshio , Wakatsuki Tetsuzo
Published: June 2007

Essential thrombocythemia (ET) can cause systemic vascular thrombosis, but involvement of coronary arteries in the setting of ET is rare. This report describes a case of acute myocardial infarction (MI) in a patient with ET. A 67-year-old man with ET complained of severe acute chest pain. Emergent coronary angiography revealed subtotal thrombotic occlusion of the left main trunk (LMT) coronary artery. Coronary angioplasty and stenting were performed successfully. Coronary angiography 4 weeks later revealed no significant restenosis. The patient has done well after primary coronary stenting with the use of only an antiplatelet agent to treat the thrombocythemia.
Daflon 500 mg and Venous Leg Ulcer: New Results From a Meta-Analysis
Authors: Smith Philip Coleridge
Published: June 2007

The objective of this study was to assess the effect of oral treatment with Daflon 500 mg (micronized purified flavonoid fraction [MPFF]) on leg ulcer healing. This study was conducted as a meta-analysis of randomized prospective studies using Daflon 500 mg as an adjunct to conventional treatment. Medical literature databases and the manufacturer’s records were searched for relevant clinical trials. Five prospective, randomized, controlled studies in which 723 patients with venous ulcers were treated between 1996 and 2001 were identified. Conventional treatment (compression and local care) in addition to Daflon 500 mg 2 tablets daily was compared with conventional treatment plus placebo in two studies (n=309), or with conventional treatment alone in three studies (n=414). The primary end point was complete ulcer healing at 6 months. The results are expressed as a reduction in the relative risk (RRR) of healing with 95% confidence intervals (CI). Since, in the present case, the desired treatment effect is increased ulcer healing, RRR should be positive to indicate a benefit of adjunctive Daflon 500 mg over conventional therapy alone. Type 1 error was set at 5%. At 6 months, the chance of ulcer healing was 32% better in patients treated with adjunctive Daflon 500 mg than in those managed by conventional therapy alone (RRR, 32%; 95% CI, 3% to 70%). This difference was present from month 2 (RRR, 44%; 95% CI, 7% to 94%), and was associated with a shorter time to healing (16 weeks vs 21 weeks; p=0.0034). The benefit of Daflon 500 mg was found in the subgroup of ulcers between 5 and 10 cm2 in area (RRR, 40%; 95% CI, 6% to 87%), as well as in patients with ulcers of 6 to 12 months’ duration (RRR, 44%; 95% CI, 6% to 97%). These results confirm that venous ulcer healing is accelerated by Daflon 500 mg treatment. Daflon 500 mg might be a useful adjunct to conventional therapy in large and longstanding ulcers that might be expected to heal slowly.
Factor V Leiden Mutation in Venous Thrombosis in Southeast Turkey
Authors: Kalkanli Sevgi , Ayyildiz Orhan , Tiftik Naci , Batun Sabri , Isikdogan Abdurrahman , Ince Hakan , Tekes Selahaddin , Muftuoglu Ekrem
Published: June 2007

Venous thrombosis (VT) is a common disease, with an annual incidence in the general population of approximately 1 per 1,000. Factor V Leiden mutation (G1691A) (FVL) is the most common risk factor in venous thrombosis. The prevalence of FVL for thrombosis varies greatly in different regions of the world. FVL mutation has been identified both by conventional method and fluorescence resonance energy transfer (FRET) with the LightCycler. Sixty-one patients with VT, different in age and sex, were consecutively entered into this study to assess the prevalence of FVL in VT in southeast Turkey. FVL mutation was found in 24.6% (15/61). Fourteen individuals were heterozygous and 1 homozygous, a rate of 22.9% and 1.6%, respectively. In conclusion, the authors suggest that FVL mutation is common in patients with venous thrombosis in southeast Turkey.
Interactions Among Habitual Physical Activity, Eating Patterns, and Diet Composition
Authors: Tsintsifa E. , Faxantidis P. , Tsiligkiroglou-Fachantidou A. , Deligiannis A.
Published: June 2007

Current public health recommendations include adequate diet and exercise in order to reduce the risk of chronic disease, especially vascular disease and other complications associated with obesity. The purpose of this study was to investigate possible relationships between the level of habitual physical activity, eating patterns, and diet composition in apparently healthy adults who exercise regularly. Subjects completed questionnaires and diaries regarding their fitness activity and nutrition. Time spent in the lowest energy expenditure category was associated with high cholesterol intakes and time spent in activities comparable to walking at a leisurely pace and light housework was associated with lower fat consumption. Fat consumption was also higher and carbohydrate consumption was lower than optimal. There was no other correlation between physical activity and the intake of any other nutrient. Further investigation is needed in sedentary populations in order to compare these findings.
Impacts of Glycoprotein IIb/IIIa Inhibition on QT Dispersion After Successful Percutaneous Coronary Intervention
Authors: Okmen Ertan , Sanli Arda , Uyarel Huseyin , Dayi Sennur , Tartan Zeynep , Cam Nese
Published: June 2007

Coronary ischemia augments inhomogeneity in ventricular repolarization. Decrease in the QT dispersion (QTd) following restoration of coronary blood flow to the ischemic myocardium by successful percutaneous coronary intervention (PCI) is an expected outcome. The purpose of the study was to seek whether glycoprotein IIb/IIIa (GP IIb/IIIa) inhibition has additional beneficial effects on QT dispersion after angiographically successful PCI. The study involved 111 consecutive patients scheduled for elective coronary balloon angioplasty with or without stent implantation. Sixty patients (mean age 58 ±9) were randomized to receive standard therapy including preprocedural aspirin, ticlopidine, and IV heparin, and 51 patients (mean age 54 ±10) were randomized to receive additional IV tirofiban infusion before the lesion was crossed with the guidewire. Standard 12-lead simultaneous ECG recordings for the measurement of QTd and corrected QTd (QTcd) (calculated by using Bazett’s formula) were obtained before and immediately after the procedure, and at the 6th, and 24th hours. Blood samples for detection of postprocedural myocardial damage (CK-MB and cTn-I) were taken before and immediately after the procedure, at the 6th, 12th, and 24th hours. In total, 128 stenoses were treated with PCI. Seventy of these lesions were in the standard therapy group and 58 in the tirofiban group. QTd and QTcd were not statistically different between the 2 groups before and immediately after the procedure and at the 6th hours, but at the 24th hour QTd and QTcd were significantly longer in the standard therapy group (p=0.047 and p=0.001, respectively). Postprocedural troponin-I elevation (B=0.692, p=0.037), maximum inflation pressure (B=0.182, p=0.001), and previous myocardial infarction (MI) (B=0.885, p=0.004) were defined as the predictors of the final QT dispersion at the 24th hour. QT dispersion significantly decreased after successful percutaneous coronary intervention. GP IIb/IIIa inhibition therapy was not superior by means of recovery of increased QT dispersion during the early hours of the intervention, but it prevented minor myocardial necrosis and provided more long-lasting recovery in QT dispersion as compared with heparin therapy. This impact of GP IIb/IIIa receptor inhibition on QTd may be a possible mechanism by which these drugs reduce cardiovascular events after PCI.
Total Serum Insulin-like Growth Factor-1 and C-Reactive Protein in Metabolic Syndrome With or Without Diabetes
Authors: Efstratiadis Georgios , Tsiaousis Georgios , Athyros Vasilios G. , Karagianni Despina , Pavlitou-Tsiontsi Aikaterini , Giannakou-Darda Anastasia , Manes Christos
Published: June 2007

There are only a few data on the relationship of insulin-like growth factor-1 (IGF-1), implicated in glucose homeostasis, and C-reactive protein (CRP), a measure of subclinical systemic inflammation, in patients with the metabolic syndrome (MetS). The authors investigated, in a cross-sectional design, the correlation between total IGF-1 and CRP in 170 subjects. Among them 123 had the MetS (National Cholesterol Program ATP III definition) and 47 did not, and 136 had type 2 diabetes mellitus (DM) and 34 did not. Anthropometric variables, clinical characteristics, as well as laboratory measurements, including total IGF-1 and CRP, were recorded. CRP levels showed a significant negative correlation with total IGF-1 concentrations, both in the whole study population ( r = -0.252, p=0.001) and the MetS group ( r = -0.203, p=0.025), regardless of the presence of DM. This correlation remained significant after adjusting for age, gender, smoking status, and waist circumference ( r = -0.18, p=0.05). Both low IGF-1 and high CRP levels had an almost linear relationship with the number of MetS components (p=0.029 and p=0.020, respectively), suggesting a close relationship of both variables with the cardiovascular disease (CVD) risk involved. The correlation between high CRP and low total IGF-1 might indicate that an increase in CRP levels may well be a key factor for the reduction in IGF-1 concentrations. Both factors are related to an increase in risk for MetS and CVD and this finding might have clinical implications in preventing or treating MetS, DM, and CVD. Given the cross-sectional design of the study, this finding should be confirmed by larger prospective and, it is hoped, interventional studies.
The Effect of Walking With High-Heeled Shoes on the Leg Venous Pressure
Authors: Potério-Filho João , Silveira Sandra Aparecida Ferreira , Potério Gloria Maria Braga , Fecuri Rubens , de Almeida Fábio Haddad Marcelino , Menezes Fábio Hüsemann
Published: June 2007

It is common belief that the use of high-heeled shoes is deleterious to venous return, by impairing the efficiency of the muscular calf pump. Ambulatory venous pressure obtained with dorsal foot venipuncture is the gold standard in the evaluation of venous pressure during walking, but it is not routinely used in clinical practice. The objective of the present study was to determine the variations in leg venous pressure obtained with a new noninvasive method, in individuals without venous disease, walking without shoes and wearing high-heeled shoes. A new method of evaluation of the venous pressure by means of air plethysmography was applied to 10 volunteers (20 limbs). The patients were evaluated while standing, with ortho-static flexion and extension foot movements, and while walking on a treadmill barefooted and wearing high-heeled shoes. It was found that the variation on the cuff pressure during walking with high-heeled shoes was higher than the variation on the cuff pressure walking barefooted (52.2 ±8.89 x 26.65 ±6.7 mm Hg, p<0.0001), and the final hydrostatic venous pressure was lower (51.5 ±12.78 x 61.5 ±8.44 mm Hg). The use of high-heeled shoes increases muscular effort during walking and diminishes the leg venous pressure compared with barefooted.
Bilateral Coronary Artery Fistulas Communicating With Main Pulmonary Artery and Left Ventricle
Authors: Cheon Won Seok , Kim Eung Ju , Kim Seong Hwan , Choi Young Jin , Rhim Chong Yun
Published: June 2007

Coronary artery fistula is an uncommon congenital malformation that generally drains into the main pulmonary artery or the right side of the heart. This is a case report on bilateral coronary artery fistulas communicating with the main pulmonary artery and the left ventricle. A 65-year-old woman was investigated for recurrent chest pain. Coronary angiography revealed this anomalous coronary artery connection without evidence of atherosclerotic coronary artery disease. The rarity of coronary artery fistulas involving both the main pulmonary artery and the left ventricle is emphasized.
The Histopathology of Varicose Vein Disease
Authors: Somers Pamela , Knaapen Michiel
Published: June 2007

Varicosity is a complex venous pathology affecting the lower extremities. The exact etiology and physiopathology of varicose vein disease remain, however, unclear. Several theories exist from incompetence of the valves to a disturbance of the smooth muscle cells (SMC) and extra-cellular matrix (ECM) organization providing a weakness of the venous wall. Multiple studies have been performed to explain the underlying mechanisms of varicosity inducing alterations in the expression patterns of the endothelium, SMC, and ECM. In that respect, most attention has been focused on the alteration of the endothelium due to blood stasis and hypoxia inducing migration/proliferation of the medial SMC into the intima. Also, studies in the deformation of the ECM induced by alterations of the expression patterns of the metalloproteinases (MMP) and their inhibitors (TIMPs) have been put forward to explain the etiology of varicosity. However, less attention has been paid to the hormonal changes that occur during pregnancy and menopause, crucial factors to be involved in the etiology of varicosity. Since alteration of the estrogen receptor-b (ERb) expression could enhance directly the cellular volume of SMC and thus the disorganization of the contractile-elastic units, hypertrophy of SMC must be accounted a pivotal role that could induce the weakness of the venous wall. Altogether, this review summarizes an overview of the latest findings of varicosity with respect to the histopathological changes of the different cellular components of the varicose vein wall related to functional and morphologic alterations.
The Open Artery Hypothesis: Beneficial Effects and Long-term Prognostic Importance of Patency of the Infarct-Related Coronary Artery
Authors: Centurión Osmar Antonio
Published: June 2007

There seem to be additional mechanisms of benefit in patients receiving late reperfusion therapy in a time when the opportunity for myocardial salvage has been missed. Previous studies have demonstrated that the restoration of blood flow in the infarct-related coronary artery in patients with acute myocardial infarction improves left ventricular function and reduces mortality. Initially, it was thought that survival was improved because viable myocardium was salvaged. However, data obtained over the past several years have suggested that the restoration of antegrade flow in the infarct-related artery may improve survival via a mechanism independent of the influence on left ventricular function. Clinical interest in the open artery hypothesis has recently resurfaced owing to a substantial improvement in technical aspects of percutaneous coronary interventions (PCI). Observational data suggest a role for late intervention as safer and more effective mechanical reperfusion practices have emerged. Long-term clinical benefits have been shown from balloon angioplasty late after myocardial infarction (MI). Therefore, patients with failed thrombolysis or those with late-presenting MI may still benefit from PCI by mechanisms independent of myocardial salvage. There is accumulative evidence on this matter. Possible mechanisms include reduction of ventricular remodeling, diminished ventricular instability reducing the incidence of arrhythmias, and provision of collaterals to other territories in the event of further coronary artery occlusion. However, caution must be exercised in interpreting the results of studies examining the open artery hypothesis. This hypothesis can be tested in its purest sense in animal experiments; however, the clinical situation is much more complex. Patients may have acute-on-chronic coronary artery occlusion in the presence of multivessel disease and well-developed collateral channels. The pattern of necrosis may also be different with areas of necrosis separated by islands of ischemic, stunned, hibernating, or normal cells. Therefore, the patency of the infarct-related coronary artery in single or multivessel disease days to weeks after infarction markedly influences long-term prognosis unrelated to improvement of left ventricular function. Current technology has made it feasible to open and maintain patency of most occluded infarct-related arteries. However, the hypothesis that late mechanical reperfusion in patients with asymptomatic occluded infarct-related artery will improve long-term clinical outcomes remains to be proved and is currently being tested in a large randomized trial.
Comparison of Clinical Characteristics of Acute Myocardial Infarction in Aborigines and Nonaborigines in Taitung Area of Taiwan
Authors: Wang Kuang-Te , Chen Chun-Yen , Hou Charles Jia-Yin , Tsai Cheng-Ho , Yeh Hung-I
Published: June 2007

This study aims to examine the correlation between acute myocardial infarction and various risk factors in eastern Taiwan as well as compare the manifestations of this serious disorder in nonaborigine and aborigine populations in the region. We collected 440 consecutive patients (308 nonaborigines and 132 aborigines) who were diagnosed with acute myocardial infarction (AMI) at the Mackay Memorial Hospital, Taitung Branch, between the years 1994 and 2001. Analysis showed that AMI was more prevalent in nonaborigines than in aborigines (0.021 ∓0.009% vs 0.011 ∓0.009%, p=0.02). In term of gender, as a whole or within each ethnic group, AMI was more predominant in men than in women (as a whole, 70%; nonaborigines, 73%; aborigines, 63%; nonaborigines vs aborigines p=0.03), and nonaborigines had more male patients. Regarding in-hospital mortality, the distribution of age (aborigine 68.2 ∓13.1 vs nonaborigine 73.5 ∓10.4, p=0.02) and percentage of smokers (aborigine 15% vs nonaborigine 32%, p=0.05) were different between the ethnic groups. Significant risk factors as a whole included the age, total cholesterol, uric acid, and the Killip Class of AMI. Multiple regression analysis showed that diabetes, age ≥70 years, uric acid ≥9.0 mg/dL, and Killip class 3 or 4 had relative risk of 1.81, 2.08, 2.89, and 1.63, respectively. However, mortality rate was not affected by ethnicity.
Percutaneous Balloon Aortic Valvuloplasty: A New Look at an Old Procedure
Authors: Sharifi Mohsen , Parhizgar Alireza , Mehdipour Mahshid , Hodge Mark , Neckels Brenda , Emrani Farnaz
Published: June 2007

There has been little change in the technical approach to balloon aortic valvuloplasty (BAV) over the last two decades. Large-caliber sheaths and extra-stiff wires have been used routinely to accommodate the large balloons used for this purpose. Consequently the morbidity (and possibly mortality) rates have been high. With the recent advances in the interventional hardware, a new look at the current approach to BAV is justified. In this report we describe an 89-year-old woman with critical aortic stenosis who underwent rapid and successful BAV by the use of a single 8-French arterial sheath, a regular (and not stiff) wire, and one peripheral balloon. We conclude that BAV can be done easily and safely with the technique and equipment described in this case report.
Secondary Nocturnal Enuresis
Authors: Robson Wm Lane M. , Leung Alexander K. C.
Published: June 2007

Secondary nocturnal enuresis accounts for about one quarter of patients with bedwetting. Although a psychological cause is responsible in some children, various other causes are possible and should be considered. This article reviews the epidemiology, psychological and social impact, causes, investigation, management, and prognosis of secondary nocturnal enuresis.
Clinical Factors Associated with Focal Infiltrates in Wheezing Infants and Toddlers
Authors: Mahabee-Gittens E. M. , Dowd M. D. , Beck J. A. , Smith S. Z.
Published: June 2007

It can be challenging to determine which findings are associated with focal infiltrates in young wheezing children. A prospective study of wheezing children ≤18 months of age revealed focal infiltrates on chest radiograph in 23%. By use of multivariate analysis, findings significantly associated with focal infiltrates included grunting (OR 4.1, 95% CI, 2.0, 8.6) and oxygen saturation≤93% (OR 2.2, 95% CI, 1.1, 4.8); with a sensitivity and specificity of 12.5% and 97%, respectively. Variables not associated with focal infiltrates included first-time wheezing, fever, and tachypnea. The combination of grunting and oxygen saturation≤93% is highly specific and can be used to help diagnose pneumonia in wheezing infants and toddlers.
Significance of a Cardiac Murmur as the Sole Clinical Sign in the Newborn
Authors: Rein Azaria J. J. T. , Omokhodion Samuel l. , Nir Amiram
Published: June 2007

A cardiac murmur is a very common finding in the first few days of life. It is traditionally believed that lesions creating left-to-right shunts do not present so early. This study was aimed to define and to classify the causes of a murmur in a newborn with an otherwise normal examination. All echocardiograms performed on newborns aged 1-5 days who were referred for evaluation of a murmur in a 3-year period were reviewed. Newborns with additional clinical signs or antenatal diagnosis of a cardiac disease were excluded. Of 20,323 live births, there were 170 newborns referred for echocardiogram solely because of a murmur. Of these, 147 (86%) were found to have structural heart defects. The most common lesions found were those creating left-to-right shunts (66%). Ventricular septal defect was the most common single lesion (54/147, 37%), followed by patent ductus arteriosus (34 newborns, 23%). The combination of both was found in 10 newborns (7%). Six newborns (4%) had pulmonary valve stenosis and three (2%) aortic valve stenosis. Seven newborns (5%) had unforeseen complex heart disease. For five of them, delayed diagnosis would have resulted in potentially life-threatening conditions. There was no correlation between the category of lesion and the age of presentation. The audible threshold of a murmur correlated with a maximum instantaneous gradient of 25 mm Hg (range 11-46 mm Hg). Thirteen percent of newborns with isolated heart murmur had no identifiable structural heart disease. These data suggest that most asymptomatic newborns presenting with a murmur in the first days of life have structural heart disease. Some of the more serious defects would not have been diagnosed without early echocardiography. A left-to-right shunt, particularly a ventricular septal defect, may cause a murmur even the first day of life and is probably more common that has been acknowledged.
Adolescents: At Increased Risk for Osteoporosis?
Authors: Cromer Barbara , Harel Zeev
Published: June 2007

Perhaps the most important factor in the primary prevention of osteoporosis is the attainment of an optimal peak bone during adolescence. In addition to endogenous factors, such as genetic and ethnic background, environmental factors such as dietary habits, physical activity, and sex hormone therapy, influence the accretion of bone mass during this critical period of skeletal growth. First, calcium dietary intake in adolescents is generally well less than the current recommended RDA of 1200 mg/day. Multiple studies of children and adolescents have demonstrated increases in bone mass with dietary calcium supplementation. Second, regarding physical activity, the overall impression is that a moderate amount of particularly weight-bearing exercise has a positive impact on bone. There appears, however, to be a threshold of intensity of physical activity over which a negative impact on bone occurs, particularly when the exercise is of an anaerobic nature or occurring in very thin, amenorrheic participants. Third, previous research suggests that the various forms of hormonal contraception exert differing effects on bone mass in adolescents, with levonorgestrel implants and combined oral contraceptives may be associated with a more positive effect on bone mass compared with that observed with depot medroxyprogesterone acetate. From a clinical perspective, approaches to optimizing peak bone mass in adolescents would include increasing calcium intake, whether in the form of dairy products, fortified foods, or supplements as well as encouraging participation at a moderate level, in weight-bearing exercise. Last, in adolescents with extensive risk factors and predicted long duration of use, subdermal implants or combined oral contraceptives may be the optimal hormonal methods of birth control.
Toxic Epidermal Necrolysis in Children—An Update
Authors: Ringheanu Mihaela , Laude Teresita A.
Published: June 2007

Toxic epidermal necrolysis (TEN) is a relatively rare disease, characterized by generalized erythema, bulla formation, and exfoliation of the epidermis that resembles scalding. It is usually drug-induced and mediated by immune reactions of several types. TEN has to be differentiated from erythema multiforme and Stevens-Johnson syndrome. TEN bears a life-threatening potential and a risk for significant complications such as dehydration; secondary infections; pulmonary, gastrointestinal, and renal involvement; and late scarring with cosmetic and functional implications. Therapeutic interventions include admission in a burn center unit, systemic antibiotics and corticosteroids, topical therapy with antibacterial agents and biological dressings, and supportive measures.
Do Parents Choose Appropriate Automotive Restraint Devices for Their Children?
Authors: Kunkel Nanette C. , Nelson Douglas S. , Schunk Jeff E.
Published: June 2007

This study aims to describe parental choices of childhood automotive restraints and compare them with guidelines based on weight and height. Parents were surveyed and their children's heights and weight were measured. Results indicated that many parents believed their child fit a lap or shoulder belt when their children were too short to fit these devices. For children weighing <40 pounds, 45% of parents believed the lap belt fit. Thirteen percent of 4-7-year-olds used booster seats, appropriate for 72% by sitting height criteria; and 33% of children <7 years used the lap/shoulder belt, appropriate for 8% by sitting height criteria. Implications are that parental perceptions of fit may lead to inappropriate restraint choices for children. Practitioners should discuss child restraint use with parents in the context of their child's weight and height.
A Review of the Role of Inhaled Corticosteroids in the Treatment of Acute Asthma
Authors: Chipps Bradley E. , Chipps Donna R.
Published: June 2007

Systemic corticosteroids (CSs) are generally accepted as treatment for acute exacerbations of asthma. In contrast, inhaled corticosteroids (ICs) have been used for the long-term management of asthma but are not widely accepted for the treatment of asthma exacerbations. The onset of action of ICs in acute asthma begins in 1 hour. In patients with mild to moderate exacerbation, administration of high-dose ICs may decrease the need for hospital admission and the number of symptomatic days.
Growth Hormone Replacement Therapy in Children with Leukemia in Remission
Authors: Taha Doris R. , Bastian William , Castells Salvador
Published: June 2007

We describe a patient with leukemia in remission for 7 years who developed growth hormone (GH) deficiency and was treated with recombinant human growth hormone (rhGH). We compare her growth with that of patients from the National Cooperative Growth Study (NCGS) database, 145 with leukemia in remission and 725 with idiopathic growth hormone deficiency (IGHD) on treatment with rhGH. We also review the literature on the risk of relapse of leukemia in similar patients. The patients with leukemia in remission from the NCGS database had a significantly lower change of mean height standard deviation score than that of IGHD patients in the first, second, and third year of rhGH treatment. The relapse rate of leukemia in patients treated with rhGH is between 0.8% and 2%. Starting rhGH therapy in patients with leukemia in remission and with GH deficiency at an adequate dosage and without undue delay would improve their growth response. Such therapy does not appear to increase the risk of leukemia.
Revising the Decision Analysis for Febrile Children at Risk for Occult Bacteremia in a Future Era of Widespread Pneumococcal Immunization
Authors: Yamamoto Loren G.
Published: June 2007

Previous decision analyses (DA), which have attempted to determine a superior management option for febrile children at risk for occult bacteremia, have come to different conclusions based on their underlying assumptions. Most DAs have recommended a laboratory evaluation with antibiotic treatment or have concluded that all management options are roughly the same. The purpose of this revised DA is to determine which management strategy will be superior in an anticipated era of widespread pneumococcal immunization. Decision analysis methodology comparing the following 3 management options: Obs: observation, no tests, no antibiotics; CBC+: Complete blood count (CBC) first; if the white blood cell count (WBC) >15,000, then blood culture (BC) plus antibiotics (Abx); BC+Abx: BC+Abx for all patients. Assumptions include a current bacteremia rate of 2% to 4%, and 95% of this bacteremia is caused by S. pneumococcus (which has a 15% persistent bacteremia rate) with the remainder caused by virulent bacteria (which has a 100% persistent bacteremia rate), and other assumptions made by previous decision analysis publications. Pneumococcal vaccine efficacy rates of 0%, 50%, 75%, and 100% in preventing pneumococcal bacteremia were analyzed. Overall death and neurologic sequelae rates are lower with efficacious pneumococcal vaccine. The Obs strategy is superior for all efficacy rates (including 0%) if the negative consequences of treatment are high. If the negative consequences of treatment are low, the CBC+ strategy is superior at pneumococcal vaccine efficacy rates of 50% or greater. The absolute differences between the outcomes of the 3 strategies are small, making them similar. This decision analysis indicates that widespread efficacious pneumococcal vaccine will reduce the overall morbidity and mortality associated with pneumococcal bacteremia. This favors the Obs strategy, but the superior management strategy is still dependent on an assumption of the negative consequences of treatment. Since the outcome measures for each of the management strategies are similar numerically, the strategy chosen in clinical practice may consider other factors associated with the clinical encounter such as those described.
Test Characteristics of the Respiratory Syncytial Virus Enzyme-Linked Immunoabsorbent Assay in Febrile Infants?60 Days of Age
Authors: Dayan Peter , Ahmad Faiz , Urtecho Jacqueline , Novick Michael , Dixon Patricia , Levine Debbie , Miller Steven
Published: June 2007

The test characteristics of rapid tests for respiratory syncytial virus (RSV) in infants may differ from older children secondary to a lower likelihood of previous illness with RSV. Our main goal was to establish the test characteristics of the RSV Abbott Testpack (TP) enzyme-linked immunoabsorbent assay (EIA) ® in febrile infants < 60 days of age. Our secondary goal was to determine the likelihood of RSV given a particular clinical syndrome and a negative or positive EIA. A prospective sample of infants with a temperature > 38.00C was evaluated during 2 successive RSV seasons. Conventional tissue and shell vial viral cultures were utilized as the reference standard. The RSV Abbott Testpack EJA® had a sensitivity of 75% (95% CI 60-90%), a specificity of 98% (95% CI 96-100%), a positive predictive value of 89% (95% CI 77-100%), a negative predictive value of 95% (95% CI 91-98%), a likelihood ratio for a positive test of 35.5 (95% CI 11.4-110.7), and a likelihood ratio for a negative test of 0.26 (95% CI 0.14-0.47). Even with a negative EIA, patients with lower and upper respiratory tract illness still had a 22.3% and 5.5% chance of harboring RSV, respectively. The RSV Abbott Testpack® is a useful diagnostic tool in the detection of RSV in febrile infants but has limitations. During months typically associated with RSV disease, a positive RSV TP indicates a high likelihood of illness, but clinicians should be wary of false negatives.
The Impact of Cobedding on Sleep Patterns in Preterm Twins
Authors: Touch Suzanne M. , Epstein Michele L. , Pohl Charles A. , Greenspan Jay S.
Published: June 2007

Interest in cobedding multiple-gestation infants has grown as focus has increased on the developmental approach to the care of the neonate. Little data, however, exist on the infants' response to cobedding. It is important to evaluate the safety, efficacy, and physiologic impact of this practice. Cobedding was offered to parents of twin infants < 37 weeks gestation, without arterial lines or ventilator requirements, by the health care team according to standard practice in our nursery. After parental informed consent, infants were placed on an event-recording cardiorespiratory monitor for 12 hours before cobedding and for the first 12 hours of cobedding. Recordings were evaluated by an investigator blinded to the bedding status of the infant. Apnea (a pause of respiration > 10 seconds, central apnea), bradycardia (a decline in heart rate to < 80 beats per minute), periodic breathing (a respiratory pattern in which there are > 3 pauses in respiration of > 3 seconds with < 20 seconds of breathing between pauses), adverse events (changes in medication, changes in oxygen requirements, temperature instability, the need for sepsis evaluation, or death) were evaluated. Other physiologic parameters were obtained through the use of standard bedside monitoring. Eleven sets of preterm infants, n = 22, with a mean gestation of 31.8 + 2.9 weeks and a mean birth weight of 1,698.7 + 552.0 grams were studied. Infants were evaluated at a corrected gestational age of 33.5 ± 1.9 weeks and a mean weight of 1,713.2 + 484.0 grams. The number of events of central apnea before cobedding (57) was greater than those recorded during cobedding (18), p<0.05. There was no difference found in any of the other parameters compared. The numbers of events recorded before and during cobedding were compared by Student's t-test and significance was determined by p < 0.05. No adverse events (AE) were noted, and all infants remained cobedded throughout the study. This preliminary study suggests that cobedding of healthy preterm twins showed no increase in adverse events. Of the physiologic parameters studied, only the occurrence of central apnea changed with cobedding. This decrease in central apnea may reflect a change in sleep pattern due to more frequent arousal by the twin. Alternatively, a more regular breathing pattern may reflect a positive physiological response to contact between twins.
Bilious Emesis in the Pediatric Emergency Department: Etiology and Outcome
Authors: Sadow Karin Berger , Atabaki Shireen M. , Johns Christina M.S. , Chamberlain James M. , Teach Stephen J.
Published: June 2007

The objective of this study was to describe the emergency department (ED) diagnoses in an unselected pediatric population with bilious emesis. In a multicenter, prospective, observational case series, a convenience sample of patients less than 21 years old with yellow or green emesis were assembled. Clinical review of each case was performed 2 weeks or longer after ED disposition. Two hundred twenty-seven patients with 230 ED encounters were enrolled. Of the 189 encounters (82.2%) with follow-up, 20 had surgical disease (10.6%; 95% C.I. 6.6%, 15.9%). There was no significant association between the color of the emesis and surgical disease (OR=2.3; 95% CI, 0.68, 8.6).
Ambulatory Blood Pressure Monitoring in Children and Adolescents
Authors: Simckes Ari M. , Srivastava Tarak , Alon Uri S.
Published: June 2007

With recent technological advances, 24-hour ambulatory blood pressure (BP) monitoring (ABPM) has become a useful tool for the evaluation, diagnosis, and management of hypertensive children. It provides a more accurate representation of an individual's BP rather than intermittent casual or office BP measurements. Hence, ABPM is being used more often to assess the BP of children. In this comprehensive review, we provide the reader with the available literature on ABPM, discuss the advantages and limitations of ABPM, and the interpretation of ABPM data. The role of ABPM in various clinical conditions and hypertension research in children is presented.
Prolonged Bottle Use and Its Association With Iron Deficiency Anemia and Overweight: A Preliminary Study
Authors: Bonuck Karen A. , Kahn Richard
Published: June 2007

To determine the prevalence of prolonged bottle feeding practices in young children, and its association with body mass index (BMI) and iron deficiency anemia (IDA), we conducted a cross-sectional survey study at 3 Bronx, NY, WIC sites. Caregivers of 95 predominantly Hispanic and African-Arnerican WIC-enrolled children aged 18-56 months presenting for recertification completed questionnaires. Half were overweight (>85th% BMI) and 36% were obese (>95th% BMI); 21% met CDC criteria for anemia. Two thirds (63%) received daily bottles of milk or sweet liquids. Daily bottle use ranged from 3 to 10 (mean=3.3, median=3). Bottle use was significantly associated with obesity (>95th% BMI, p<0.0005), not significant with overweight (>85th% BMI, p<0.06) and statistically significant with IDA.
Antiemetic Use in Pediatric Gastroenteritis: A National Survey of Emergency Physicians, Pediatricians, and Pediatric Emergency Physicians
Authors: Kwon Kenneth T. , Rudkin Scott E. , Langdorf Mark l.
Published: June 2007

The objective of this study was to review the use of antiemetics for pediatric gastroenteritis and to determine prescribing patterns of physicians. A mailed cross-sectional survey instrument was sent to randomly selected board-certified emergency medicine, pediatric, and pediatric emergency medicine specialists. A total of 1665 surveys were mailed, with 593 completed surveys returned (35.6% response rate). A majority of responders (60.9%) reported using antiemetics for pediatric gastroenteritis at least once in the past year, with a greater than 50% usage for all three specialty groups. Promethazine was the most commonly used antiemetic in all specialties, and per rectum the most common route of administration. Adverse reactions following a single dose of antiemetic were most frequently reported with prochlorperazine. The most common reason for antiemetic use was to prevent further dehydration. The most common concern regarding antiemetic use was potential for side effects. Occasional antiemetic use appears to be a common practice in treating pediatric gastroenteritis, regardless of specialty. Given the absence of literature on efficacy or safety, these drugs should be used only with careful consideration to potential side effects.
Ethical Conflicts Between Residents and Attending Physicians
Authors: Levi Benjamin H.
Published: June 2007

Conflicts between residents and attending physicians over ethical issues often occur and residents must attempt to navigate these perilous waters. A brief description of a conflict concerning informed consent and professional role expectations in a neonatal intensive care unit is presented. The discussion then explores contextual features that often shape such ethical conflicts and presents ways of understanding ethical conflicts that occur in the course of medical training. Constructive approaches for residents to engage in conflict resolution are offered.
Melatonin in Children and Adolescents with Insomnia: A Retrospective Study
Authors: Ivanenko Anna , Crabtree Valerie McLaughlin , Tauman Riva , Gozal David
Published: June 2007

Effectiveness and tolerability of melatonin was assessed in 32 children (mean age 9.6 + 4.5 years) with chronic sleep initiation and sleep maintenance problems treated naturalistically in a pediatric sleep medicine center. Children received melatonin for an average of 2.1 ± 2.0 months at a final average dose of 2.0 ± 1.2 mg administered 1 hour before bedtime. Twenty-nine (90.6%) children exhibited partial improvement to complete resolution of their sleep problems as measured by sleep latency time and number of awakenings reported by parents. Thus, melatonin may be effective, safe, and well tolerated in the treatment of chronic insomnia in children.
Adolescent Risk Behavior Screening: The Difference Between Patients Who Come in Frequently and Infrequently
Authors: Zink Therese M. , Levin Linda , Rosenthal Susan L.
Published: June 2007

Charts were examined retrospectively to identify evidence of risk behavior screening in adolescents, identified from billing data as visiting at least 9 times during a 1-year period (n=55), frequent attenders (FA). These were matched 2:1 on age, gender, and ethnicity with 121 nonfrequent attenders (NFA),?3 visits in 1 year. FA had more evidence of risk behavior screening than NFA, but less preventive care. Risk screening in males occurred less than in females in both FA and NFA. Chart review demonstrated many missed opportunities. Providers are encouraged to fully utilize well teen exams as well as acute visits for risk behavior screening.