bluuebunny/crossref_metadata_2025 huggingface dataset:
Experience with the sternocleidomastoid myoperiosteal flap for reconstruction of subglottic and tracheal defects: Modification of technique and report of long‐term results
Authors: Friedman Michael , Toriumi Dean M. , Owens Ruth , Grybauskas Vytenis T.
Published: October 2006

Subglottic or tracheal reconstruction may be required in cases of subglottic stenosis, invasive thyroid carcinoma, or trauma. The sternocleidomastoid myoperiosteal flap uses clavicular periosteum on a muscle pedicle to provide vascularity. Clavicular periosteum is fibrous, durable, and will conform to the shape of the trachea, forming bone to provide stability to the airway. The procedure is relatively simple and involves single‐staged reconstruction.

After 4 years' experience with this flap, we present the results from a series of 11 patients who underwent subglottic or tracheal reconstruction with the sternocleidomastoid myoperiosteal flap. Ten of 11 patients were successfully decannulated. The average time from reconstruction to decannulation was 50.3 days. Follow‐up ranged from 12 to 40 months. We also describe modifications of the initial technique that have been introduced to improve the flap's versatility and effectiveness.
Management of juvenile angiofibromata
Authors: Spector J. Gershon
Published: October 2006

Twenty‐eight angiofibromata, treated between 1971 and 1988, were reviewed according to their patterns of invasion, blood supply, treatment modality, and clinical course. All patients were males, and two patients were black. The average age was 14.8 years. Nasopharyngeal masses, epistaxis, and facial asymmetry were the most common presenting symptoms. Tumors extended along predetermined pathways following the vascularity of the external carotid system. CNS extension arose via the superior orbital fissure or direct extension from the sphenoid sinus. Angiography described the neoplastic vascularity, CT with contrast demonstrated tumor location and extracranial extension, and MRI best demonstrated CNS invasion.

All lesions were reclassified according to the American Joint Committee staging system. Twenty‐seven patients were operated upon; four with cryotherapy and 23 following embolization. Two tumors recurred and needed additional surgery. One patient with CNS invasion was treated with estrogen and radiotherapy for cure. Tumor staging is not particularly helpful in decision making, because surgery must be individualized according to tumor location and extent. Surgical approaches for specific tumor locations are discussed.
Percutaneous gastrostomy: The stanford experience
Authors: Luetzow Annette M. , Chaffoo Richard A. K. , Young Harvey
Published: October 2006

Many techniques have been devised to provide enteral nutrition to the patient with cancer of the head and neck. No single technique will be adequate for all patients, but our experience with percutaneous gastrostomy has encouraged us to recommend it as a valuable alternative to conventional modalities. The charts of 156 patients, identified by computer‐assisted search as having undergone gastrostomy at Stanford University Hospital or Palo Alto Veterans Administration Hospital from 1984 to 1987, were reviewed. Of these, 24 patients with a primary diagnosis of head and neck malignancy underwent percutaneous gastrostomy and form the basis for this study. Parameters evaluated included operation time, type of anesthesia, perioperative complications, and cost. Percutaneous gastrostomy can be performed under local anesthesia or at the time of routine head and neck procedures such as staging endoscopy. Our success with this technique leads us to recommend it as a valuable alternative for providing nutrition to head and neck cancer patients.
Temporal bone pneumatization in cystic fibrosis patients
Authors: Todd N. Wendell , Martin W. Stephen
Published: October 2006

Cystic fibrosis patients commonly have nasal polyps and sinusitis, but surprisingly are spared from an increased occurrence of otitis media. Twenty cystic fibrosis patients whose ages ranged from 13 to 2G years were studied. Only one of these patients had a history of otitis. Minimal temporal bone pneumatization, as determined by computed tomography, was used as an indicator of childhood otitis. The computed tomography had been done as part of the medical evaluation of their symptomatic paranasal sinusitis.

On the average, pneumatization volume was larger for the cystic fibrosis patients than for the normal population (p=0.033, Student's t‐test). That is, these data indicate that cystic fibrosis patients had significantly less otitis than the normal population. Assuming that these cystic fibrosis patients are representative, the data may imply that the gene for good musculoskeletal eustachian differentiation is linked with the gene for cystic fibrosis. The data also imply that poor mucociliary transport does not necessarily induce otitis media.
The role of haemophilus influenzae in the pathogenesis of tonsillar hypertrophy in children
Authors: Brodsky Linda , Moore Linda , Stanievich John
Published: October 2006

The role of specific bacteria in the pathogenesis of tonsillar hypertrophy in children in unknown. To determine the effect of specific bacteria on the presence and nature of tonsillar hypertrophy (measured both clinically and by tonsil weight), quantitative aerobic bacteriology was performed on 54 tonsil‐core specimens from 54 children undergoing tonsillectomy for chronic tonsillitis and/or tonsillar hypertrophy. Twelve tonsil‐core biopsies from 12 children with no history of tonsil disease served as controls.

Haemophilus influenzae (HI), Streptococcus pyogenes (SP), Streptococcus pneumoniae (SPn), and Staphylococcus aureus (SA) were the most common microorganisms cultured from diseased tonsils. Few bacteria were cultured from the cores of controls. HI was cultured as the dominant aerobic bacteria in 15 of 54 tonsils (27%). For HI alone, the number of bacteria/gram tonsil showed a significant positive correlation to tonsil weight (p<0.05). Fourteen of 15 (94%) tonsils with HI were found in patients with clinical tonsillar hypertrophy, while only 6 of 10 patients (60%) with SP and SPn had tonsillar hypertrophy. Of the 38 tonsils removed for obstructive symptoms (clinical hypertrophy), 14 of 38 (37%) cultured HI as the dominant microorganism, whereas only 6 of 38 (16%) cultured SP. Neither the type of HI (b us. non‐b) nor the presence of beta‐lactamase production had a significant correlation to tonsil weight, bacterial load or the number of B‐ or T‐cell subsets.

The number of T‐helper (T), T‐suppressor (T) and B‐cells (per gram/tonsil) was markedly greater in all diseased tonsils than in controls. For both HI and SP the total number of bacteria/gram tonsil correlated positively to the number of T cells (p<0.003 and p<0.007, respectively). In patients with HI type b (HI‐b), the tonsil weight correlated to an increase in T and B‐cells (p<0.004 and p<0.007, respectively). An increased presence of the T and B‐cells in the HI‐b tonsils (and not in tonsils with HI non‐b) suggests a differential response by the tonsil to these distinct but related bacteria.

The above data strongly support an etiological role for HI in the pathogenesis of tonsillar hypertrophy in children. Alterations in the relationship between T and T cells may affect normal B‐cell function and be implicated in this phenomenon. Clinical implications for pathogenesis, antimicrobial therapy, and future directions for research are discussed.
New imaging techniques in diagnosis of cerebrospinal fluid fistula
Authors: Nicklaus Pamela , Dutcher Paul O. , Hengerer Arthur S. , Kido Daniel K. , Nelson Curtis N.
Published: October 2006

The localization of a cerebrospinal fluid fistula producing cerebrospinal fluid otorrhea can be very difficult. However, the exact anatomic localization of the bony defect is important when selecting the surgical approach to repair. Case reports of two patients in whom spontaneous cerebrospinal fluid otorrhea occurred following pressure equalization tube placement for middle‐ear effusion are presented. Nuclear magnetic imaging supplemented CT scan findings, providing noninvasive localization of the defect. Preoperative impressions were confirmed at surgery. In addition to discussing the use of magnetic resonance imaging in evaluating cerebrospinal fluid otorrhea, the literature will also be reviewed.
Comparison of benefit from vibrotactile aid and cochlear implant for postlinguistically deaf adults
Authors: Skinner Margaret W. , Binzer Susan M. , Smith Peter G. , Holden Laura K. , Fredrickson John M. , Holden Timothy A. , Juelich Margaret F. , Turner Beverly A.
Published: October 2006

Four postlinguistically deaf adults were evaluated presurgically with a one‐ or two‐channel vibrotactile aid and postsurgically with a multichannel, multielectrode, intracochlear implant. Although the vibrotactile aid provided awareness of sound and enhanced flow of conversation, benefit to lipreading was small on videotaped tests and speech tracking. Scores on recorded, sound‐only speech tests were not significantly above chance except in discrimination of noise from voice. With the cochlear implant, benefit to lipreading was significantly greater than with the vibrotactile aid, and scores on sound‐only tests were significantly above chance. Communication was markedly better with the implant than with the vibrotactile aid. In counseling those who get no benefit from a hearing aid, the results of this study provide data on the amount of benefit one‐ or two‐channel vibrotactile aids provide postlinguistically deaf adults who are subsequently implanted.
Evaluation of five different cochlear implant designs: Audiologic assessment and predictors of performance
Authors: Tyler Richard S. , Abbas Paul , Tye‐Murray Nancy , Gantz Bruce J. , Knutson John F. , Mccabe Brian F. , Lansing Charissa , Brown Carolyn , Woodworth George , Hinrichs James , Kuk Francis
Published: October 2006

The audiologic performance of 54 postlingually deafened adults wearing cochlear implants was uniformly evaluated. The participants had 9 months' or more experience with one of five different cochlear prostheses (Los Angeles Single Channel (N = 11), Vienna Single Channel (N = 4), Melbourne Multichannel (N = 18), Utah Multichannel (N = 19), San Francisco Multichannel (N = 2). The multichannel designs enabled participants to recognize more environmental sounds, provided more speech reading enhancement, and enabled most users to understand limited speech in the sound‐only condition, compared to the single‐channel implant group.
Antimicrobial prophylaxis in ear surgery
Authors: Jackson C. Gary
Published: October 2006

The purpose of this research was to assess the efficacy of prophylactic antibiotic administration in ear surgery over a wide range of cases. Additional objectives include the assessment of the relative effect of patient age, duration of operation, preoperative condition, and the success of tympanoplasty.

Prospectively, in a controlled study, 4,000 patients were studied employing cephalosporin and oxacillin as prophylactic antimicrobials. No statistically significant difference in postoperative otologic infection rates was observed. This conclusion was unaltered by the operative duration, patient age, or preoperative condition. Grafting success was not improved.

Antimicrobial prophylaxis in ear surgery cannot be recommended.
Analysis of immunocompetent cells following inner ear immunostimulation
Authors: Takahashi Mitsuaki , Harris Jeffrey P.
Published: October 2006

Immunohistochemical methods were used to investigate the development of inner ear immunocompetent cells in healthy, BALB/c mice over a 3‐week period as a result of a secondary inner ear response against keyhole limpet hemocyanin. Antibodies against murine macrophages and granulocytes (anti‐Mac‐1), T‐cells (anti‐Lyt‐1, anti‐Lyt‐2), and immunoglobulins (anti‐IgM, anti‐IgG, anti‐IgA) were used. Mac‐1 positive (Mac‐1) cells were observed at 6 hours post‐challenge in the endolymphatic sac and cochlea and rapidly increased in both sites. Lyt‐1 cells gradually increased in the endolymphatic sac after challenge, peaking at 2 and 3 weeks post‐challenge. In the cochlea, Lyt‐1 cells were detected at 1 day post‐challenge and then increased. Lyt‐2 cells were detectable in the endolymphatic sac and the cochlea by 3 weeks post‐challenge. The predominant immunoglobulin‐bearing cell in the endolymphatic sac was IgG, followed by IgM, with IgA seen late in the response. We conclude that the inner ear has the capacity to mount an immune response through the accumulation of the needed immunocompetent cells for antigen processing, antibody production, and modulation of the response through T‐helper and suppressor cell activity.
Minor salivary gland tumors of the lip and buccal mucosa
Authors: Weber Randal S. , Guillamondegui Oscar M. , Byers Robert M. , Palmer J. Mark , El‐Naggar Adel , Mcneese Marsha D.
Published: October 2006

Between 1944 and 1985, 50 patients with minor salivary gland tumors of the lip and buccal mucosa were treated at M. D. Anderson Cancer Center: 19 with lip and 31 with buccal mucosa tumors. The male‐to‐female ratios were 2.8:1 for lip and 1:2.9 for the buccal mucosa tumors. Patient age at presentation ranged from 18 to 98 years with a median of 55 years. Treatment consisted of surgery alone for 28 patients, radiotherapy in 9 patients, and combined therapy for 13. Adenoid cystic carcinoma was the predominant histologic type, accounting for 21 (42%) tumors. Risk for recurrence was influenced by histology, the presence of perineural invasion, and the location of the primary tumor. Six patients developed recurrent disease; all six had adenoid cystic carcinoma. The therapeutic approach and the rationale for combined treatment of these neoplasms are discussed.
Normal auditory brainstem response in patients with acoustic neuroma
Authors: Telian Steven A. , Niparko John K. , Kemink John L. , Graham Malcolm D. , Kileny Paul R.
Published: October 2006

Auditory brainstem response testing has been a major breakthrough in audiologic screening for acoustic neuroma because of its high degree of sensitivity. Although it is not uncommon for other cerebellopontine angle masses to present with normal ABR findings, reports of eighth nerve tumors with false‐negative auditory brainstem response tests are quite rare. A series of 120 acoustic neuromas resected at the University of Michigan was reviewed and revealed two such patients. These two patients presented with asymmetric sensorineural hearing loss and unilateral tinnitus and were found to have completely normal auditory brainstem response. The diagnosis of acoustic neuroma would have been delayed if a comprehensive evaluation had not been pursued.
Hemorrhagic tonsillitis
Authors: Levy Simon , Brodsky Linda , Stanievich John
Published: October 2006

Eleven patients with acute and/or chronic tonsillitis, who presented with a spontaneous tonsillar hemorrhage are reported and discussed. Two patterns of hemorrhage were noted: 1. diffuse, parenchymal bleeding and 2. localized bleeding from dilated surface vessels.

Pharyngeal culture for group A bela‐hemolytic Streptococcus was positive in six patients (55%). Monospot, heterophile antibodies, complete blood cell count, prothombin time, partial thromboplastin time, and viral studies did not consistently demonstrate any abnormality. Two patients, however, did have an elevation in liver enzymes. In five patients, the bleeding stopped spontaneously; in five patients the bleeding was controlled with local chemical cautery. In two patients, Avitene® was used for hemostasis. One other patient's bleeding was controlled by electrocautery while the patient was under anesthesia for endoscopic evaluation of hemoptysis. Two patients required blood transfusions; one of these patients had a history of factor IX deficiency.

Four case histories are discussed in detail to illustrate the varied clinical presentation and some pitfalls in diagnosing and managing this rarely reported complication of tonsillitis. Possible mechanisms for the pathophysiology include increased tonsillar blood flow, necrosis of tonsillar surface cells, and trauma to dilated surface vessels. No common bacterial or viral etiology could be determined in this rare, but potentially serious, complication of tonsillitis.
Histopathology of bell's palsy
Authors: Liston Stephen L. , Kleid M. Stephen
Published: October 2006

The histopathology of the facial nerve 1 week after the onset of Bell's palsy is reported. The entire nerve was infiltrated by inflammatory cells. Myelin breakdown, axonal changes, and edema were present, suggesting viral neuritis. The role of decompression in this disease process is discussed.
Facial nerve function following irradiated cable grafts
Authors: McGuirt W. Frederick , Welling D. Bradley , Mccabe Brian F.
Published: October 2006

Facial nerve cable grafting preceding postoperative radiation therapy in patients undergoing facial nerve resection for malignant disease remains controversial. Twelve cases of postoperatively irradiated facial nerve cable grafts are reviewed in detail. Of nine patients with long‐term evaluations, all have shown some return of facial nerve function, with seven having moderate to excellent return of function, as documented on videotapes and shown in still photographs.

We conclude that cable grafting is the treatment of choice, even though postoperative radiation therapy is planned. Cable grafting should almost always result in facial function that is clearly superior to the function provided by static or dynamic slings.
Changes in Pharyngeal Properties After Uvulopalatopharyngoplasty
Authors: Wright Stanley , Zamel Noe , Haight James , Hoffstein Victor
Published: October 2006

Uvulopalatopharyngoplasty is a commonly used modality for surgical treatment of snoring and obstructive sleep apnea. Although this procedure is thought to alter pharyngeal properties, its effect on pharyngeal mechanics has not been studied. The acoustic reflection technique was used to measure pharyngeal area at functional residual capacity and residual volume before and after uvulopalatopharyngoplasty in eight patients referred because of loud snoring. We also calculated the lung volume dependence of pharyngeal area, defined as the percent change in pharyngeal area between functional residual capacity and residual volume, normalized to the area at functional residual capacity. This parameter, which may be related to pharyngeal collapsibility, was obtained before and after uvulopalatopharyngoplasty. Preoperative sleep studies showed that one patient had obstructive sleep apnea (apnea index > 10). Uvulopalatopharyngoplasty resulted in a significant increase (p<0.01) in pharyngeal area (from 3.14 ± 0.71 cm1 to 4.25 ± 1.07 cm2) and residual volume (from 2.49±0.53 cm2 to 3.91±0.83 cm2). Following uvulopalatopharyngoplasty, the pharynx became stiffer, as manifested by a reduction in lung volume dependence of pharyngeal area from 19±12% to 8±13% (p<0.05). Six patients, including the patient with obstructive sleep apnea, reported improvement in snoring. Two patients reported worsening in snoring. One of the two was found to have reduction in pharyngeal area and lung volume dependence of pharyngeal area, and an increase in apnea index from 3 to 33. In selected snorers, uvulopalatopharyngoplasty results in improvement in snoring with a concomitant increase in pharyngeal area and a tendency toward lower pharyngeal collapsibility.
Oncogenic Osteomalacia: Exact Tumor Localization by Co-Registration of Positron Emission and Computed Tomography
Authors: Hesse Eric , Moessinger Eckart , Rosenthal Herbert , Laenger Florian , Brabant Georg , Petrich Thorsten , Gratz Klaus F , Bastian Leonard
Published: October 2006

In oncogenic osteomalacia, the causative tumor is almost always difficult to find. A novel diagnostic approach is presented that facilitates a precise and rapid localization of the associated lesion by PET-CT co-registration using the radiotracer 68Ga-DOTANOC.

In oncogenic osteomalacia, the causative tumor is almost always difficult to find. A novel diagnostic approach is presented that facilitates a precise and rapid localization of the associated lesion by PET-CT co-registration using the radiotracer 68Ga-DOTANOC.

Introduction: Oncogenic osteomalacia (OOM) is an uncommon disorder characterized by hyperphosphaturia, hypophosphatemia, decreased vitamin D3 serum levels, and osteomalacia. The paraneoplastic syndrome is exclusively driven by a small somatostatin receptor (sst)-positive tumor that produces phosphatonins, proteins that cause renal phosphate loss. OOM can be cured completely on tumor removal. However, the exact tumor localization is the most challenging step, because the lesion is notoriously difficult to detect by common imaging techniques.

Materials and Methods: A 60-year-old woman complained of severe pain in her back and chest wall, muscle weakness, and reduced physical activity for >1 year. She suffered a metatarsal fracture and presented with hyperphosphaturia and hypophosphatemia. OOM was suspected, and a meticulous search for the tumor was initiated by conventional imaging techniques, sst-mediated imaging using 111In-octreotide scintigraphy, and 68Ga-DOTANOC-based positron emission tomography (PET)-CT co-registration. 68Ga-DOTANOC is a novel radiopharmaceutical compound in which the somatostatin analog octreotide is modified at position 3, chelated with DOTA, and complexed with 68Gallium. 68Ga-DOTANOC has an improved affinity to sst2 and sst5 relative to other radiopeptides.

Results: Whereas common imaging techniques such as CT failed to localize the tumor, 111In-octreotide scintigraphy was able to detect the lesion, but only PET-CT using 68Ga-DOTANOC revealed the exact tumor localization in the right femoral head. On tumor resection, the well being of the patient improved significantly, and biochemical parameters returned to normal.

Conclusions: 68Ga-DOTANOC-based PET-CT is a novel and powerful approach to detect sst-positive tumors in a timely manner and to provide highly resolved images facilitating the development of a therapeutic strategy.
Development of Hand Function and Precision Grip Control in Individuals With Cerebral Palsy: A 13-Year Follow-up Study
Authors: Eliasson Ann-Christin , Forssberg Hans , Hung Ya-Ching , Gordon Andrew M.
Published: October 2006

OBJECTIVE. Although children with cerebral palsy display large developmental differences in hand function from that of typically developing children by the age of 6 to 10 years, little is known about the developmental processes underlying hand function during subsequent development. In this study we investigated the development of manual dexterity in a timed motor task, the timing and amplitude of fingertip-force application during a precision grasping task, and the relationship between changes in these measures. We applied highly quantitative analytical approaches to determine if the fingertip-force application pattern and trial-to-trial variation of fingertip-force application change during development.

METHODS. Twelve subjects with cerebral palsy (aged 6–8 years) participated in the first data-collection session conducted between 1989 and 1990. Ten of these subjects (5 with hemiplegia and 5 with diplegia, aged 19–21 years) returned between 2002 and 2003. Manual dexterity was measured by using timed tasks of the Jebsen-Taylor test of hand function. Subjects also lifted an object instrumented with force transducers while we measured the temporal coordination of fingertip coordination and the path ratio between the grip and vertical load-force trajectory (straightness). We used generalized procrustes analysis to determine if there were changes in shape of the force trajectory and intertrial variability.

RESULTS. The Jebsen-Taylor test times decreased 45% from the first to the second data session. The overall time to complete the grip-lift task decreased 22%, mainly because of a faster transition from grasp to lift. The grip-force/load-force path ratios decreased from 1.7 to 1.35 (1 = straight line). Generalized procrustes analysis indicated a change in the shape and a decrease in variability in shape of the force-ratio path.

CONCLUSIONS. Our results demonstrate that the efficiency in grasping had developed during a 13-year period for this small group of participants with cerebral palsy, which suggests that improvement in hand function occurs over a longer time frame than commonly would be expected.
Cost of Outpatient Medical Care for Children and Youth With Special Health Care Needs: Investigating the Impact of the Medical Home
Authors: Damiano Peter C. , Momany Elizabeth T. , Tyler Margaret C. , Penziner Andrew J. , Lobas Jeffrey G.
Published: October 2006

OBJECTIVE. Our goal was to evaluate the impact of having a medical home on the outpatient medical costs of children and youth with special health care needs.

DESIGN. Data from 2 sources were matched at the individual level: (1) the 2002 Iowa Consumer Assessment of Health Plans Study survey of Medicaid enrollees and (2) Iowa Medicaid administrative claims, encounter, and enrollment files.

PARTICIPANTS. The subjects were 1140 children aged 6 months to 12 years for whom both sources of data were available.

MAIN OUTCOME MEASURE(S). Outcomes measures included medical homeness, as developed by a scale of items in the Consumer Assessment of Health Plans Study survey, and outpatient costs, as determined from Medicaid administrative data.

RESULTS. From the regression models, we found that (1) for all Medicaid-enrolled children, outpatient costs were significantly higher for female children and children and youth with special health care needs, (2) for children and youth without special health care needs, costs were significantly higher for female children, those with a personal doctor or nurse, and those with more of a medical home, and (3) for children and youth with special health care needs, costs were significantly higher for those in a lower health state, for those in health maintenance organization 2, and for older children.

CONCLUSIONS. Although the degree of medical homeness was not related to outpatient costs for children and youth with special health care needs, medical homeness may affect inpatient costs more than outpatient costs for children and youth with special health care needs and should be investigated further.
The Impact of Conjugate Pneumococcal Vaccination on Routine Childhood Vaccination and Primary Care Use in 2 Counties
Authors: Szilagyi Peter G. , Griffin Marie R. , Shone Laura P. , Barth Richard , Zhu Yuwei , Schaffer Stanley , Ambrose Sandra , Roy Jason , Poehling Katherine A. , Edwards Kathryn M. , Walker Frances J. , Schwartz Benjamin ,   for the New Vaccine Surveillance Network
Published: October 2006

BACKGROUND. Pneumococcal conjugate vaccine immunization recommendations were rapidly implemented by primary care providers. Before the recommendations, concern was expressed that adding pneumococcal conjugate vaccine might result in delays in other vaccinations or preventive services.

OBJECTIVES. The study objectives were to measure whether incorporation of pneumococcal conjugate vaccine by primary care providers delayed other vaccinations or added primary health care visits.

DESIGN AND METHODS. In 2 counties surrounding Rochester and Nashville, we reviewed a representative sample of primary care charts for children born before and after licensure of pneumococcal conjugate vaccine. Receipt of vaccinations and health care visits were compared for the 2 age-matched cohorts.

RESULTS. We reviewed 1459 records from Rochester and 1857 records from Nashville. The pre–pneumococcal conjugate vaccine and post–pneumococcal conjugate vaccine cohorts had similar demographic characteristics. The median age for receipt of any vaccination was not older for the postvaccine cohort than for the prevaccine cohort in either community. The percentage of children up-to-date for vaccinations by 18 months for postvaccine versus prevaccine cohorts was similar in Rochester (72% in each cohort) and in Nashville (58% postvaccine and 65% prevaccine). The number of well-child care visits or other health care visits during the first 18 months of life was not statistically different between the 2 cohorts.

CONCLUSIONS. Implementation of pneumococcal conjugate vaccine was not associated with delays in other childhood vaccinations or more primary care visits.
Screening for Developmental Delay in the Setting of a Community Pediatric Clinic: A Prospective Assessment of Parent-Report Questionnaires
Authors: Rydz David , Srour Myriam , Oskoui Maryam , Marget Nancy , Shiller Mitchell , Birnbaum Rena , Majnemer Annette , Shevell Michael I.
Published: October 2006

OBJECTIVES. Our goal for this study was to prospectively test whether parent-completed questionnaires can be effectively used in the setting of a busy ambulatory pediatric clinic to accurately screen for developmental impairments. Specific objectives included (1) assessing the feasibility of using parent-report instruments in the setting of a community pediatric clinic, (2) evaluating the accuracy of 2 available screening tests (the Ages and Stages Questionnaire and Child Development Inventory), and (3) ascertaining if the pediatrician's clinical judgment could be used as a potential modifier.

METHODS. Subjects were recruited from the patient population of a community clinic providing primary ambulatory pediatric care. Subjects without previous developmental delay or concerns noted were contacted at the time of their routine 18-month-old visit. Those subjects who agreed to participate were randomly assigned to 1 of 2 groups and completed either the Ages and Stages Questionnaire or Child Development Inventory. The child's pediatrician also completed a brief questionnaire regarding his or her opinion of the child's development. Those children for whom concerns were identified by either questionnaire underwent additional detailed testing by the Battelle Development Inventory, the “gold standard” for the purposes of this study. An equal number of children scoring within the norms of the screening measures also underwent testing with the Battelle Development Inventory.

RESULTS. Of the 356 parents contacted, 317 parents (90%) agreed to participate. Most parents correctly completed the Ages and Stages Questionnaire (81%) and the Child Development Inventory (75%). Predictive values were calculated for the Ages and Stages Questionnaire and the Child Development Inventory (sensitivity: 0.67 and 0.50; specificity: 0.39 and 0.86; positive predictive value: 34% and 50%; negative predictive value: 71% and 86%, respectively). Incorporating the physician's opinion regarding the developmental status of the child did not improve the accuracy of the screening questionnaires.

CONCLUSIONS. Three important conclusions were reached: (1) parent-completed questionnaires can be feasibly used in the setting of a pediatric clinic; (2) the pediatrician's opinion had little effect in ameliorating the accuracy of either questionnaire; and (3) single-point accuracy of these screening instruments in a community setting did not meet the requisite standard for development screening tests as set by current recommendations. This study raises important questions about how developmental screening can be performed, and we recommend additional research to elucidate a successful screening procedure.
Adverse Events in the Neonatal Intensive Care Unit: Development, Testing, and Findings of an NICU-Focused Trigger Tool to Identify Harm in North American NICUs
Authors: Sharek Paul J. , Horbar Jeffrey D. , Mason Wilbert , Bisarya Hema , Thurm Cary W. , Suresh Gautham , Gray James E. , Edwards William H. , Goldmann Donald , Classen David
Published: October 2006

OBJECTIVES. Currently there are few practical methods to identify and measure harm to hospitalized children. Patients in NICUs are at high risk and warrant a detailed assessment of harm to guide patient safety efforts. The purpose of this work was to develop a NICU-focused tool for adverse event detection and to describe the incidence of adverse events in NICUs identified by this tool.

METHODS. A NICU-focused trigger tool for adverse event detection was developed and tested. Fifty patients from each site with a minimum 2-day NICU stay were randomly selected. All adverse events identified using the trigger tool were evaluated for severity, preventability, ability to mitigate, ability to identify the event earlier, and presence of associated occurrence report. Each trigger, and the entire tool, was evaluated for positive predictive value. Study chart reviewers, in aggregate, identified 88.0% of all potential triggers and 92.4% of all potential adverse events.

RESULTS. Review of 749 randomly selected charts from 15 NICUs revealed 2218 triggers or 2.96 per patient, and 554 unique adverse events or 0.74 per patient. The positive predictive value of the trigger tool was 0.38. Adverse event rates were higher for patients <28 weeks' gestation and <1500 g birth weight. Fifty-six percent of all adverse events were deemed preventable; 16% could have been identified earlier, and 6% could have been mitigated more effectively. Only 8% of adverse events were identified in existing hospital-based occurrence reports. The most common adverse events identified were nosocomial infections, catheter infiltrates, and abnormal cranial imaging.

CONCLUSIONS. Adverse event rates in the NICU setting are substantially higher than previously described. Many adverse events resulted in permanent harm and the majority were classified as preventable. Only 8% were identified using traditional voluntary reporting methods. Our NICU-focused trigger tool appears efficient and effective at identifying adverse events.
Comparison of the 4-Digit Diagnostic Code and the Hoyme Diagnostic Guidelines for Fetal Alcohol Spectrum Disorders
Authors: Astley Susan J.
Published: October 2006

OBJECTIVE. The 4-Digit Diagnostic Code for fetal alcohol spectrum disorders and the Hoyme fetal alcohol spectrum disorders diagnostic guidelines differ markedly. The performances of the 2 diagnostic systems were compared.

METHODS. The fetal alcohol syndrome diagnostic criteria from the 4-Digit Code and Hoyme guidelines were applied to 952 patients who had received an interdisciplinary, fetal alcohol spectrum disorders, diagnostic evaluation at the University of Washington with the 4-Digit Diagnostic Code and 16 children with confirmed absence of prenatal alcohol exposure.

RESULTS. The prevalence of fetal alcohol syndrome was 3.7% with the 4-Digit Code and 4.1% with the Hoyme guidelines. Although the prevalences were similar, the patients identified were not. Only 17 individuals met the fetal alcohol syndrome criteria for both systems. An extraordinary number of patients (35%) met the Hoyme criteria for the fetal alcohol syndrome facial phenotype, but only 39 of those 330 patients met the Hoyme criteria for fetal alcohol syndrome. Even some children with no alcohol exposure (25%) had the Hoyme fetal alcohol syndrome face. The specificities of the Hoyme fetal alcohol syndrome face for the Hoyme fetal alcohol syndrome diagnosis and prenatal alcohol exposure were low in these populations.

CONCLUSIONS. Without a specific facial phenotype, a valid diagnosis of fetal alcohol syndrome cannot be rendered for patients with prenatal alcohol exposure, because a causal link between their outcomes and exposure cannot be established, and a valid diagnosis of fetal alcohol syndrome cannot be rendered for patients with unknown alcohol exposure, because the face cannot serve as a valid proxy measure for alcohol exposure. Diagnostic guidelines must confirm the specificity of their fetal alcohol syndrome facial criteria to validate their diagnostic criteria.
The Psychosocial Problems of Children With Narcolepsy and Those With Excessive Daytime Sleepiness of Uncertain Origin
Authors: Stores Gregory , Montgomery Paul , Wiggs Luci
Published: October 2006

BACKGROUND. Narcolepsy is a predominantly rapid eye movement sleep disorder with onset usually in the second decade but often in earlier childhood. Classically it is characterized by combinations of excessive sleepiness especially sleep attacks, cataplexy, hypnagogic hallucinations, and sleep paralysis. The psychosocial effects of this lifelong condition are not well documented, especially in children. This study aims to describe the psychosocial profile of a large group of children with narcolepsy compared with other excessively sleepy children and controls.

METHODS. We used an international cross-sectional questionnaire survey of children aged from 4 to 18 years who had received from a physician a diagnosis of narcolepsy compared with age- and gender-matched controls. Assessments were made of behavior, mood, quality of life, and educational aspects.

RESULTS. Recruited children were separated into those who met conventional criteria for narcolepsy (n = 42) and those whose primary complaint was excessive daytime sleepiness without definite additional features of narcolepsy (excessive daytime sleepiness group; n = 18). Compared with controls, children with narcolepsy and also those with excessive daytime sleepiness alone showed significantly higher rates of behavioral problems and depression. Again, to a significant extent, their quality of life was poorer and they had more educational problems. The children with narcolepsy and the excessive daytime sleepiness group were indistinguishable from each other on these measures.

CONCLUSIONS. A range of psychosocial problems can be identified in children with narcolepsy. The origins of these problems are unclear. The similar profiles of difficulties in the narcolepsy and excessive daytime sleepiness groups suggest that excessive sleepiness is the main cause. Clinicians and others responsible for the care of such children need to be mindful of the importance of early detection, intervention, and, ideally, the prevention of these problems.
The Burden of Diabetes Mellitus Among US Youth: Prevalence Estimates From the SEARCH for Diabetes in Youth Study
Authors:   SEARCH for Diabetes in Youth Study Group
Published: October 2006

OBJECTIVE. Our goal was to estimate the prevalence of diabetes mellitus in youth <20 years of age in 2001 in the United States, according to age, gender, race/ethnicity, and diabetes type.

METHODS. The SEARCH for Diabetes in Youth Study is a 6-center observational study conducting population-based ascertainment of physician-diagnosed diabetes in youth. Census-based denominators for 4 geographically based centers and enrollment data for 2 health plan-based centers were used to calculate prevalence. Age-, gender-, and racial/ethnic group-specific prevalence rates were multiplied by US population counts to estimate the total number of US youth with diabetes.

RESULTS. We identified 6379 US youth with diabetes in 2001, in a population of ∼3.5 million. Crude prevalence was estimated as 1.82 cases per 1000 youth, being much lower for youth 0 to 9 years of age (0.79 cases per 1000 youth) than for those 10 to 19 years of age (2.80 cases per 1000 youth). Non-Hispanic white youth had the highest prevalence (1.06 cases per 1000 youth) in the younger group. Among 10- to 19-year-old youth, black youth (3.22 cases per 1000 youth) and non-Hispanic white youth (3.18 cases per 1000 youth) had the highest rates, followed by American Indian youth (2.28 cases per 1000 youth), Hispanic youth (2.18 cases per 1000 youth), and Asian/Pacific Islander youth (1.34 cases per 1000 youth). Among younger children, type 1 diabetes accounted for ≥80% of diabetes; among older youth, the proportion of type 2 diabetes ranged from 6% (0.19 cases per 1000 youth for non-Hispanic white youth) to 76% (1.74 cases per 1000 youth for American Indian youth). We estimated that 154369 youth had physician-diagnosed diabetes in 2001 in the United States.

CONCLUSIONS. The overall prevalence estimate for diabetes in children and adolescents was ∼0.18%. Type 2 diabetes was found in all racial/ethnic groups but generally was less common than type 1, except in American Indian youth.
Adverse Effects in Children After Unintentional Buprenorphine Exposure
Authors: Geib Ann-Jeannette , Babu Kavita , Ewald Michele Burns , Boyer Edward W.
Published: October 2006

Buprenorphine in sublingual formulation was recently introduced to the American market for treatment of opioid dependence. We report a series of 5 toddlers with respiratory and mental-status depression after unintentional buprenorphine exposure. Despite buprenorphine’s partial agonist activity and ceiling effect on respiratory depression, all children required hospital admission and either opioid-antagonist therapy or mechanical ventilation. Results of routine urine toxicology screening for opioids were negative in all cases. Confirmatory testing was sent for 1 child and returned with a positive result. The increasing use of buprenorphine as a home-based therapy for opioid addiction in the United States raises public health concerns for the pediatric population.
No Evidence of Persisting Measles Virus in Peripheral Blood Mononuclear Cells From Children With Autism Spectrum Disorder
Authors: D’Souza Yasmin , Fombonne Eric , Ward Brian J.
Published: October 2006

OBJECTIVES. Despite epidemiologic evidence to the contrary, claims of an association between measles-mumps-rubella vaccination and the development of autism have persisted. Such claims are based primarily on the identification of measles virus nucleic acids in tissues and body fluids by polymerase chain reaction. We sought to determine whether measles virus nucleic acids persist in children with autism spectrum disorder compared with control children.

PATIENTS AND METHODS. Peripheral blood mononuclear cells were isolated from 54 children with autism spectrum disorder and 34 developmentally normal children, and up to 4 real-time polymerase chain reaction assays and 2 nested polymerase chain reaction assays were performed. These assays targeted the nucleoprotein, fusion, and hemagglutinin genes of measles virus using previously published primer pairs with detection by SYBR green I. Our own real-time assay targeted the fusion gene using novel primers and an internal fluorescent probe. Positive reactions were evaluated rigorously, and amplicons were sequenced. Finally, anti-measles antibody titers were measured by enzyme immunoassay.

RESULTS. The real-time assays based on previously published primers gave rise to a large number of positive reactions in both autism spectrum disorder and control samples. Almost all of the positive reactions in these assays were eliminated by evaluation of melting curves and amplicon band size. The amplicons for the remaining positive reactions were cloned and sequenced. No sample from either autism spectrum disorder or control groups was found to contain nucleic acids from any measles virus gene. In the nested polymerase chain reaction and in-house assays, none of the samples yielded positive results. Furthermore, there was no difference in anti-measles antibody titers between the autism and control groups.

INTERPRETATION. There is no evidence of measles virus persistence in the peripheral blood mononuclear cells of children with autism spectrum disorder.
Pediatric Mental Health Emergencies in the Emergency Medical Services System
Authors:   American Academy Of Pediatrics,   Committee on Pediatric Emergency Medicine,   American College Of Emergency Physicians,   Pediatric Emergency Medicine Committee
Published: October 2006

This Policy Statement was reaffirmed June 2009, April 2013, and April 2020.

Emergency departments are vital in the management of pediatric patients with mental health emergencies. Pediatric mental health emergencies are an increasing part of emergency medical practice because emergency departments have become the safety net for a fragmented mental health infrastructure that is experiencing critical shortages in services in all sectors. Emergency departments must safely, humanely, and in a culturally and developmentally appropriate manner manage pediatric patients with undiagnosed and known mental illnesses, including those with mental retardation, autistic spectrum disorders, and attention-deficit/hyperactivity disorder and those experiencing a behavioral crisis. Emergency departments also manage patients with suicidal ideation, depression, escalating aggression, substance abuse, posttraumatic stress disorder, and maltreatment and those exposed to violence and unexpected deaths. Emergency departments must address not only the physical but also the mental health needs of patients during and after mass-casualty incidents and disasters. The American Academy of Pediatrics and the American College of Emergency Physicians support advocacy for increased mental health resources, including improved pediatric mental health tools for the emergency department, increased mental health insurance coverage, and adequate reimbursement at all levels; acknowledgment of the importance of the child’s medical home; and promotion of education and research for mental health emergencies.
Payment for Telephone Care
Authors:   Section on Telephone Care,   Committee on Child Health Financing
Published: October 2006

Telephone care in pediatrics requires medical judgment, is associated with practice expense and medical liability risk, and can often substitute for more costly face-to-face care. Despite this, physicians are infrequently paid by patients or third-party payors for medical services provided by telephone. As the costs of maintaining a practice continue to increase, pediatricians are increasingly seeking payment for the time and work involved in telephone care. This statement reviews the role of telephone care in pediatric practice, the current state of payment for telephone care, and the practical issues associated with charging for telephone care services, a service traditionally provided gratis to patients and families. Specific recommendations are presented for appropriate documenting, reporting, and billing for telephone care services.
ESTABLISHMENT OF MANDS FOLLOWING TACT TRAINING AS A FUNCTION OF REINFORCER STRENGTH
Authors: Wallace Michele D. , Iwata Brian A. , Hanley Gregory P.
Published: October 2006

We examined some conditions under which a response acquired as a tact might facilitate the establishment of a mand. We taught 3 participants with developmental disabilities to tact the items ranked highest and lowest in a preference assessment and subsequently tested to see if the responses occurred as mands. All participants manded for the highly preferred item but rarely manded for the nonpreferred item. These results indicate that, although tact and mand functions are different, conditions can be created to facilitate transfer from the former to the latter. Implications for communication training are discussed.
EFFECTS OF GUIDED NOTES VERSUS COMPLETED NOTES DURING LECTURES ON COLLEGE STUDENTS' QUIZ PERFORMANCE
Authors: Neef Nancy A. , McCord Brandon E. , Ferreri Summer J.
Published: October 2006

We compared the effects of guided lecture notes versus completed lecture notes on pre‐ to postlecture improvements in quiz performance across two sections of a college course. The results of a counterbalanced multielement design did not reveal consistent differences between the two note formats on students' mean quiz scores. However, fewer errors occurred on complex (analysis‐level) quiz questions in the guided notes condition than in the completed notes condition.