bluuebunny/crossref_metadata_2025 huggingface dataset:
CLOSING OF MEDICAL SCHOOLS
Authors: L. J. F.
Published: December 2021

A private study commission is urging "the wholesale closing" of US medical schools during the next decade to avert a glut of doctors.

The Pew Health Professions Commission on Thursday urged a similar retrenchment ent in pharmacy schools and elimination of at least 10% of nurse training programs.

It called for constricting the pipeline of foreign doctors who come to this country to train and usually wind up practicing here.

. . . The provocative study, funded by the Pew Charitable Trusts, a private philanthropy, did not sit well with leaders of academic medicine.
EVIDENCE-BASED EDITING—AT LAST!
Authors: Student
Published: December 2021

Editors and others are beginning to research the process of peer review. Most questions about the peer review process cannot yet be answered on the basis of evidence, but some can: for instance, we have evidence that blinding reviewers to the identity of authors leads them to produce better opinions and that structured abstracts contain more information than unstructured ones.
The Relationship Between Pertussis Vaccine and Central Nervous System Sequelae: Continuing Assessment
Authors:   COMMITTEE ON INFECTIOUS DISEASES
Published: December 2021

Reassessment of the role of whole-cell pertussis vaccine as a cause of permanent neurologic damage is necessitated by the 10-year follow-up of the National Childhood Encephalopathy Study (NCES) in Great Britain. The findings of this study demonstrate that infants and young children with serious acute neurologic disorders are at an increased risk of later neurologic impairment or death, irrespective of the initial precipitating event. The results, however, do not establish a causal relationship between pertussis vaccination and chronic neurologic abnormalities. The Academy reaffirms its earlier conclusion that whole-cell pertussis vaccine has not been proven to be a cause of brain damage and continues to recommend pertussis vaccination in accordance with the guidelines in the 1994 Red Book.
Update on Tuberculosis Skin Testing of Children
Authors:   COMMITTEE ON INFECTIOUS DISEASES
Published: December 2021

In January 1994, the Committee on Infectious Diseases published detailed guidelines on tuberculin skin testing of infants, children, and adolescents for the detection of tuberculous infections. This supplement to the 1994 statement is written to update and clarify several issues regarding the frequency of skin testing for children at increased risk of acquiring tuberculosis. In this document, children will refer to infants, children, and adolescents. The recommendations regarding the preferred use of the Mantoux skin test and the interpretation of skin test results remain unchanged and will not be repeated here. The interpretation guidelines for indurations of 5, 10, and 15 mm in diameter basically remain unchanged (Table 1).

The overall emphasis to control tuberculosis in the United States should be placed on access to health care, a thorough history taking of exposure to infectious persons, timely and effective contact investigations, proper interpretation of Mantoux skin tests, and appropriate use of therapy, including directly observed therapy. Variations in the epidemiology of tuberculosis in different locations reinforce the importance of communication with local public health officials and/or experts on tuberculosis. Existing publications can assist in assessing the local risk of acquiring tuberculosis. The recommendations should be considered regardless of previous BCG vaccine administration.

The American Academy of Pediatrics continues to encourage focusing tuberculin skin testing on children who are at increased risk of acquiring tuberculosis. Routine tuberculin testing, including school-based programs that include populations at low risk, has either a low yield of positive results or a large number of false-positive results and represents an inefficient use of limited health care resources.
THE HEALTH POLICE
Authors: Student
Published: December 2021

... the new lifestyle police ... identify danger—usually invisible and undetectable by the normal senses—and then urge the introduction of legislation or other controls to make the environment safe...

... Should every mouthful of food and drink be assessed for its potential health effects? ... The health police should ask themselves whether they are adding or subtracting from the total sum of human happiness.
Adenosine Infusion Improves Oxygenation in Term Infants With Respiratory Failure
Authors: Konduri G. Ganesh , Garcia Daisy C. , Kazzi Nadya J. , Shankaran Seetha
Published: December 2021

Objective. Adenosine infusion causes selective pulmonary vasodilation in fetal and neonatal lambs with pulmonary hypertension. We investigated the effects of a continuous infusion of adenosine on oxygenation in term infants with persistent pulmonary hypertension of newborn (PPHN).

Design. A randomized, placebo-controlled, masked trial comparing the efficacy of intravenous infusion of adenosine to normal saline infusion over a 24-hour period.

Setting. Inborn and outborn level III neonatal intensive care units at a university medical center.

Participants. Eighteen term infants with PPHN and arterial postductal Po2 of 60 to 100 Torr on inspired O2 concentration of 100% and optimal hyperventilation (PaCo2 <30 Torr) were enrolled into the study. Study infants were randomly assigned to receive a placebo infusion of normal saline, or adenosine infusion in doses of 25 to 50 µg/kg/min over a 24-hour period.

Results. Nine infants each received adenosine or placebo. The two groups did not differ in birth weight, gestational age, or blood gases and ventilator requirements at the time of entry into the study. Four of nine infants in the adenosine group and none of the placebo group had a significant improvement in oxygenation, defined as an increase in postductal PaO2 of ≥20 Torr from preinfusion baseline. The mean PaO2 in the adenosine group increased from 69 ± 19 at baseline to 94 ± 15 during 50 µg/kg/min infusion rate of adenosine and did not change significantly in the placebo group. Arterial blood pressure and heart rate did not change during the study in either group. The need for extracorporeal membrane oxygenation, incidence of bronchopulmonary dysplasia, and mortality were not different in the two groups.

Conclusion. Data from this pilot study indicate that adenosine infusion at a dose of 50 µg/kg/min improves PaO2 in infants with PPHN without causing hypotension or tachycardia. Larger trials are needed to determine its effects on mortality and/or need for extracorporeal membrane oxygenation in infants with PPHN.
NICU-Net: An Electronic Forum for Neonatology
Authors: TARCZY-HORNOCH PETER
Published: December 2021

The neonatology list server NICU-Net was created over a year ago at the University of Washington as an international forum for neonatologists and other neonatal health care providers. The stated purpose was discussion of neonatal issues such as: recently published trials and recommendations, proposed or ongoing multicenter trials, dilemmas in diagnosis, management and ethics, and the effects of health care reform on neonatology. Much like the forums of Rome, NICU-Net was intended to be a "place" of public assembly for discussion and debate. To allow access to the greatest number of potential users, it was set up as a mailing list server that allows anybody with Internet electronic mail (E-mail) access to participate.
E COLI STRIKES VEGETARIANS? ..
Authors: L. J. F.
Published: December 2021

... Vegetables grown in soil fertilized with only partially composted animal manure can be contaminated with the potentially deadly E coli bacteria, which is most often found in meat. Self-defense: Before eating, thoroughly wash all fruits and vegetables.
Biliary Atresia, Cytomegalovirus, and Age at Referral
Authors: Tarr Phillip I. , Haas Joel E. , Christie Dennis L.
Published: December 2021

Objective. To determine the frequency with which patients with extrahepatic biliary atresia (EHBA) are infected with cytomegalovirus (CMV) and to ascertain the age at referral to a specialty center for surgical correction of EHBA.

Methods. The charts of all patients discharged from the Children's Hospital and Medical Center between July 1, 1989 and December 31, 1993 with a new diagnosis of EHBA were reviewed to determine the frequency with which EHBA was accompanied by CMV infection. Data analyzed included age at referral and sex of patients, histopathologic evidence of CMV infection and size of bile ducts in the resected liver, and serologic (IgM) or culture diagnosis of CMV infection.

Results. Twenty-three patients with EHBA were evaluated at Children's Hospital and Medical Center in the study period. Twenty-one of the patients with EHBA were appropriately evaluated for infection with CMV and infection was documented in 5 (24%) patients. The median age of referral for all patients was 61 days (range 10 to 124 days). Infected patients were referred later (82.4 ± 28.7 days) than noninfected patients (48.8 ± 21.8 days) (P = .01) and were more likely to be girls, but the medians of the diameters of the bile ducts in the resected porta hepatis were similar. Viral inclusions were not identified in any of the liver specimens.

Conclusions. CMV infection is present in an unexpectedly large proportion of patients with EHBA at the time of referral. The establishment of CMV infection in infants with cholestasis should not deter the search for EHBA. Physicians should strive to reduce the age of referral of patients with EHBA to pediatric surgical centers by evaluating infants who remained jaundiced at 4 weeks of age.
Emotional Problems During Youth as Predictors of Stature During Early Adulthood: Results From a Prospective Epidemiologic Study
Authors: Pine Daniel S. , Cohen Patricia , Brook Judith
Published: December 2021

Objective. Adults with emotional disorders exhibit abnormalities in growth hormone secretion. If these abnormalities were to occur during childhood, they could affect growth. The purpose of this study was to examine the relationship between youth emotional disorders and stature in early adulthood.

Methods. Using data from a prospective epidemiologic study of youth psychopathologic status, we used linear regression to examine the prospective relationship between anxiety disorders (separation anxiety and overanxious disorders) or major depressive disorder in youth and stature in early adulthood.

Results. Anxiety disorders during childhood prospectively predicted relatively short stature in early adulthood among females, accounting for more than 5% of the variance in adult height. However, these associations were not found among males.

Conclusions. There may be an association between abnormalities in growth and emotional problems in youth. Further research should examine biological measures related to growth among youth with emotional disorders.
The Role of the Pediatrician in Prescribing Therapy Services for Children With Motor Disabilities
Authors:   Committee on Children With Disabilities
Published: December 2021

Pediatricians are often called upon to prescribe physical and occupational therapy service for children with motor disabilities. This statement defines the context in which rehabilitation therapies should be prescribed, emphasizing the identification and enhancement of the child's function and abilities. The statement encourages the pediatrician to work with teams including the parents, child, teachers, therapists, and other physicians.
The Interface Between Dysmorphology and Epidemiology in the "Diagnosis" and Surveillance for Fetal Alcohol Effects
Authors: Khoury Muin J. , Boyle Coleen , DeCoufle Pierre , Floyd Louise , Hymbaughm Karen
Published: December 2021

We read with great interest the commentary of Aase et al entitled "Do we need the term fetal alcohol effects (FAE)?"1 As a public health agency, the Centers for Disease Control and Prevention (CDC) has been working with states and academic organizations to develop and evaluate prevention programs for fetal alcohol syndrome (FAS). A fundamental component of such programs is the design and implementation of population-based surveillance systems for FAS to track the magnitude of the problem to assess temporal trends related to intervention programs.2,3
THE EFFECTS OF INTRANASAL STEROIDS ON NASAL AND PULMONARY RESPONSES TO CAT EXPOSURE
Authors: Szefler Stanley J.
Published: December 2021

Intranasal corticosteroid treatment led to significant reductions in both upper and lower airway responses to intense cat exposure.
PREVENTIVE THERAPY FOR ASTHMA IN CHILDREN: A 9-YEAR EXPERIENCE IN EASTERN FINLAND
Authors: Joos Thad H.
Published: December 2021

Purpose of the Study. The investigation was carried out to ascertain if the treatment of childhood asthma in Finland changed after the publication of consensus guidelines in 1989 in Europe.

Methods. In a well-defined geographic area of Finland with about 53 000 children under 15 years of age, the asthma care for most youngsters was given through a regional allergy center headed by a pediatric allergist. Patient records were reviewed every other year from 1985 to 1993 regarding methods of treatment such as the use of long-term preventative agents, theophylline, and sympathomimetics amines.

Results. The results were most impressive regarding the use of sodium cromoglycate, which showed a marked increase in usage beginning in 1987 so that by 1993, 58% of the asthmatic children used this compound. Inhaled steroids remained rather constant over the 5 years surveyed, the figure being 20% of the children. Slow-release theophylline products dropped considerably as did sympathomimetic agents.

Reviewer's Comments. I feel that with the widespread use of inhaled prevention medications during 1987 through 1989 for children with asthma, our Finnish colleagues were perhaps 2 to 3 years ahead of us in America.
CLINICAL VALUE OF MONITORING EOSINOPHIL ACTIVITY IN ASTHMA
Authors: Joos Thad H.
Published: December 2021

Purpose of the Study. Eosinophils are recognized as an integral part of the inflammatory aspect of bronchial asthma. One of their granulocyte-derived proteins, eosinophilic cationic protein (ECP) has been shown in in vitro studies to be deleterious to the bronchial mucosa. The present investigation was carried out in an effort to determine if the total eosinophil count and serum ECP levels could be correlated with the degree of bronchial reactivity as seen in asthmatic children.

Methods. A total of 175 asthmatic children with a mean age of 9.8 years were divided into five treatment groups: 1) B2 agents only; 2) inhaled steroids; 3) inhaled steroids and a B2 agent; 4) cromolyn sodium; and 5) a group of newly diagnosed asthmatics treated with inhaled steroids and a B2 agent. The comparison groups were: 1) 23 nonasthmatic children with lower respiratory tract infections; 2) 45 children with stable cystic fibrosis; and 3) 87 healthy children with no atopic or asthmatic history. Pulmonary function studies were performed in all children capable of cooperating when normal and ill. Total eosinophil counts and ECP levels were determined at these times as well. The newly diagnosed asthmatics were serially followed by the above parameters every 2 weeks for 6 weeks.

Results. They found the following:

1) Total eosinophil counts were significantly elevated primarily in the atopic asthmatic, but were not correlated with asthmatic activity;

2) ECP levels were persistently elevated in the cystic fibrosis group;

3) ECP levels in the asthmatic group did, indeed, correlate with the disease activity, with atopic asthmatics having higher levels than their nonatopic counterparts.
OBJECTIVE MEASUREMENTS OF COMPLIANCE IN ASTHMA TREATMENT
Authors: Marino Joseph T.
Published: December 2021

The authors conclude that although self-management and self-monitoring are the basis for present day national and international asthma treatment programs, this may not be realistic. They emphasized that, although these were knowledgeable patients who were educated with a video, written material, one-on-one discussion, and were able to use devices, there was still a high rate of noncompliance and a significant rate of deception.
AIRWAY EDEMA POTENTIATES AIRWAY REACTIVITY
Authors: Parry David E. , Lemanske Robert F.
Published: December 2021

Acute volume loading with saline causes an increase in airway wall thickness and a decrease in airway area and a subsequent enhanced constrictor response to aerosolized histamine. Although this study examines effects of acute edema, to the extent that chronic inflammation (such as in asthma) leads to increased vascular permeability, airway edema and increased responsiveness, acute or chronic edema should have similar effects on airway responsiveness.
SAFETY AND ACTIVITY OF SAQUINAVIR IN HIV INFECTION
Authors: Parry Davod E. , Lemanske Robert F.
Published: December 2021

Purpose of the Study. To assess the in vivo antiviral activity and tolerability of saquinavir in a dose-response study design.

Study Population. Forty-nine adult male, zidovudinenaive, human immunodeficiency virus (HIV)-positive patients with few or no symptoms of HIV infection and CD4 counts less than 500/mm3.

Methods. Patients were stratified according to symptoms or no symptoms of HIV infection and were randomized to receive saquinavir at 25 mg (10 patients), 75 mg (12 patients), 200 mg (12 patients), or 600 mg (10 patients) all orally tid for 16 weeks. Five patients in each group had symptoms of HIV infection. Patients were evaluated at baseline, weekly for the first 4 weeks and then at 6, 8, 12 and 16 weeks. Virus isolation and quantification was performed at baseline and 4-weekly intervals. HIV RNA was measured by polymerase chain reaction (PCR). No statistical tests were performed.

Results. Trends were reported and depicted graphically in the article. Patients in the higher dosage groups (particularly 600 mg tid) showed increasing CD4 counts and a reduction in viral load as measured by quantitative PCR for HIV RNA over the treatment period. Little difference was seen between the two lower dosage treatment groups. Data from all patients (including 8 who did not complete the 16 weeks of study) were analyzed for drug tolerability; reported adverse events were mild and considered by investigators mostly to be unrelated to the treatment.

Conclusions and Reviewers' Comments. Saquinavir is a highly specific inhibitor of HIV proteases that are essential for the final assembly of viable viral particles in HIV replication.
ASSOCIATION OF EPSTEIN-BARR VIRUS WITH LEIOMYOSARCOMAS IN YOUNG PEOPLE WITH AIDS
Authors: Navarro Maritza , Hanson I. Celine
Published: December 2021

EBV was found in all smooth muscle tumors from the six HIV-infected cases, but not in smooth muscle tumors from HIV-negative controls. All tumors studied stained for CD21 (EBV receptor), but levels were higher on tumor cells from HIV-infected cases than controls. This suggests that perturbation of the immune system (as in AIDS) may increase the production of the EBV receptor and/or that EBV infection itself causes increased receptor expression. It is postulated that EBV may contribute to smooth muscle tumorigenesis in HIV infection and potentially in other immunosuppressed states.
LOSS OF CYTOTOXIC T LYMPHOCYTE FUNCTION IN CHEDIAK-HIGASHI SYNDROME ARISES FROM A SECRETORY DEFECT THAT PREVENTS LYTIC GRANULE EXOCYTOSIS
Authors: Sullivan Kathleen E.
Published: December 2021

Cytotoxic T cells from a patient with chediak-Higashi syndrome formed giant lytic granules that were not secreted in response to stimulation. This led to abnormal cytolytic function. The authors conclude that the molecular defect in Chediak-Higashi syndrome lies in a protein that is generally involved in vesicle fusion and is crucial for the secretion of lysosomal contents for cells of the hematopoietic lineage.
IMMUNOHISTOLOGIC ANALYSIS OF INEFFECTIVE CD40-CD40 LIGAND INTERACTION IN LYMPHOID TISSUES FROM PATIENTS WITH X-LINKED IMMUNODEFICIENCY WITH HYPER-IgM
Authors: Sullivan Kathleen E.
Published: December 2021

The functional development of B cell follicles and follicular dendritic cells require CD40-CD40 ligand interactions. Both of these abnormalities probably contribute to the immunodeficiency in HIGMX-1.
Acute Response to Inhaled Nitric Oxide in Newborns With Respiratory Failure and Pulmonary Hypertension
Authors: Day Ronald W. , Lynch Joanna M. , White Keith S. , Ward Robert M.
Published: December 2021

Objective. Systemic oxygenation is improved by inhaled nitric oxide therapy in some newborns with respiratory failure and pulmonary hypertension. Our results with inhaled nitric oxide were reviewed to determine factors associated with an acute improvement in systemic oxygenation.

Methods. Newborns with oxygenation indices of 25 to 40 were prospectively randomized to receive conventional therapy with or without 20 ppm inhaled nitric oxide. All newborns with oxygenation indices greater than 40 were treated with inhaled nitric oxide. Hemodynamic, blood gas, and Doppler ultrasound measurements were performed before and after 30 to 60 minutes of observation or therapy. The severity of lung disease was classified by the chest radiograph as: (1) normal or focal disease; (2) moderate diffuse disease—diffuse lung disease with well-defined heart borders; or (3) severe diffuse disease—diffuse lung opacification with indistinct heart borders.

Results. Heart rate, blood pressure, and ductal diameters did not change. Blood gases and ductal shunting acutely improved only in patients treated with inhaled nitric oxide. Patients with normal lung fields or focal disease had the greatest degree of improvement in systemic oxygenation. Changes in oxygenation were not influenced by gestational age, baseline blood gases, the proportion of right-to-left ductal shunting, prior treatment with a surfactant, or the use of conventional or high-frequency jet ventilation. Collectively, blood gases and ductal shunting did not improve with inhaled nitric oxide in patients with lung hypoplasia or severe diffuse lung disease. Sustained improvement in oxygenation occurred in 87% of patients with oxygenation indices greater than 40 in whom oxygenation indices less than 40 acutely developed after exposure to nitric oxide, whereas 90% of patients in whom oxygenation indices less than 40 did not acutely develop were treated with extracorporeal membrane oxygenation or ultimately died.

Conclusions. Inhaled nitric oxide acutely improves systemic oxygenation in many newborns with respiratory failure and pulmonary hypertension. The diagnosis and chest radiograph are helpful in identifying patients who will have favorable acute responses to therapy. In patients with severe hypoxemia, the need for invasive support with extracorporeal membrane oxygenation may be determined by an acute trial of inhaled nitric oxide.
Chronic Pain in Cystic Fibrosis
Authors: Ravilly Sophie , Robinson Walter , Suresh Santhanam , Wohl Mary Ellen , Berde Charles B.
Published: December 2021

Objective. The objective of this study was to examine the incidence and therapy of chronic pain in a group of older patients with cystic fibrosis (CF).

Patients. We identified two groups of patients followed at the CF Center at Children's Hospital (Boston); the first group consisted of all patients above the age of 5 years who died between 1984 and 1993, and the second was a cohort of 23 additional CF patients who had been referred to the Pain Treatment Service.

Design. Medical charts were reviewed for the etiology and therapy of all pain episodes requiring medical intervention.

Results. The incidence of chronic pain in this population increased sharply in the last 6 months of life. Headaches (55% of patients) and chest pain (65%) were frequently reported, although back pain (19%), abdominal pain (19%), and limb pain (16%) were also reported. In patients with headache, the main etiologies were hypercarbia or hypoxia, migraine, and sinusitis. The majority of chest pain was musculoskeletal, with pleuritis, pneumothorax, and rib fracture also reported as the cause of chest pain.

Interventions. A variety of nonpharmacological and pharmacological therapies were reported. Forty-one patients (53%) had pain severe enough to require opioid treatment, and 10 patients (13%) received opioids for more than 3 months. In eight patients with more severe pain, regional analgesia was found to be particularly effective.

Conclusions. Chronic pain is a common problem in CF, particularly as the patient population ages. When administered with caution, opioids have proven to be effective and safe in this population; regional anesthesia can be used to preserve pulmonary toilet while adequately treating severe pain.
Predictors of Weight Loss in Children With Attention Deficit Hyperactivity Disorder Treated With Stimulant Medication
Authors: Schertz Mitchell , Adesman Andrew R. , Alfieri Nancy E. , Bienkowski Robert S.
Published: December 2021

Objective. A retrospective study was undertaken to examine predictors of weight loss in children with attention deficit hyperactivity disorder (ADHD) treated with stimulant medication.

Design. Children diagnosed with ADHD and treated with methylphenidate hydrochloride (MPH) or dextroamphetamine sulfate (DEX) for at least 5 months were identified by retrospective chart review. Analyses were performed on 32 children (29 boys) treated with MPH and 28 children (25 boys) treated with DEX. Variables examined included pretreatment weight, pretreatment body mass index (BMI), duration of treatment, total daily dose, and weight-adjusted dose.

Results. The MPH-treated group was initially seen at a mean age (± standard deviation) of 7.5 years (±2.1). Mean duration of follow-up was 11.2 months (±3.8). Mean total daily dose was 25.5 mg (±8.2) and mean weight-adjusted dose was 1.0 mg/kg/day (±.5). Mean change in weight as expressed in z scores was -0.4 SD (±.7). The DEX-treated group was initially seen at a mean age of 9.3 years (±2.7). Mean duration of follow-up was 10.8 months (±4.1). Mean total daily dose was 14.9 mg (±8.2) and mean weight-adjusted dose was .5 mg/kg/day (±.3). Mean change in weight was -0.6 SD (±.6). Although the MPH group was younger than the DEX group, there were no between-group differences in weight or height either before treatment or at follow-up when adjusted for age and gender. Using linear regression analysis, significant correlations were found between pretreatment weight and change in weight for both the MPH-treated group (r = .63) and the DEX-treated group (r = .47). Stepwise multiple-regression analysis indicated that pretreatment age, weight-adjusted dose, and duration of follow-up did not significantly contribute to the variance in change of weight for either the MPH- or DEX-treated groups. To adjust for height, changes in BMI were also analyzed. For both medication groups, no differences were found between the heavier (BMI≥50%) and thinner (BMI <50%) children in duration of follow up, total daily dose, or weight-adjusted dose. When the medication groups were combined, a greater proportion of heavier children experienced a decrease relative to their predicted BMI compared with thinner children (80% vs 52%). Comparisons of mean BMI slopes revealed that the heavier group experienced an absolute decrease in their BMI (-.139) in contrast to the thinner group (+.014) (t = 2.70).

Conclusions. Pretreatment weight, adjusted for age, gender, and height, is a significant predictor of weight loss in children with ADHD treated with either MPH or DEX. In contrast, pretreatment age, duration of treatment, and weight-adjusted dose were not found to be significant predictors.
Introduction
Authors: Friedman Stanford B. , Schonberg S. Kenneth , Sharkey Mary
Published: December 2021

Pediatricians routinely advise parents on a wide range of child earing issues. Among the most difficult and controversial topics included in professional guidance is the use of corporal punishment and, in particular, spanking. There are those who believe that corporal punishment contributes to later violence, whereas others believe spanking is a legitimate component of the overall process of discipline. Most of us base our views about the appropriateness and effectiveness of corporal punishment on our own previous experiences when we were disciplined as children and/or how we raise (or plan to raise) our own children. In contrast, advice offered to parents regarding discipline is seldom based on an appraisal of the relevant behavioral literature. Consequently, there is no agreement among the members of the American Academy of Pediatrics regarding the use of spanking. A recent attempt at evolving a policy statement addressing this issue failed to achieve consensus among the members of the Board of the Academy. Thus, disagreement persists regarding whether the Academy should recommend that pediatricians advise parents as to whether they should, or should not, spank their children. And if so, under what circumstances?

The planners of this conferences were in search of data-based scientific answers to these questions. Towards this end, recognized investigators were invited to present and discuss research findings, and develop a series of consensus statements reflecting the current state of our scientific knowledge on the short- and long-term consequences of corporal punishment.

In February 1996, 24 participants met at the Academy offices in Elk Grove Village, Illinois.
Outcomes of Extremely Low Birth Weight Infants
Authors: Hack Maureen , Friedman Harriet , Fanaroff Avroy A.
Published: December 2021

Background. Our goal was to determine the effects of recent changes in delivery room and neonatal care, including surfactant and dexamethasone therapy, on survival, neonatal morbidity, and 20-month neurodevelopmental outcome of infants with birth weights of less than 750 g.

Methods. We compared the outcomes of 114 infants of 500 to 750 g birth weight delivered at our perinatal center between January 1990 and December 1992 (period II), when surfactant and postnatal dexamethasone were used, with the outcomes of 166 such infants born between July 1982 and June 1988 (period I).

Results. The rate of cesarean section increased from 17% to 27% and delivery room intubation increased from 54% to 72% during periods I and II, respectively. Survival increased from 23% during period I to 43% during period II. The increase in survival was significant at birth weights of 600 to 700 g and at 24 weeks' gestation and greater. During period II fewer infants died at less than 24 hours of age and more died at more than 28 days of life. Neonatal morbidity did not change appreciably; neither did 20-month neurodevelopmental outcomes. Twenty percent of the infants had subnormal cognitive function (Mental Development Indices < 70) and 10% had cerebral palsy during period II.

Conclusions. Despite an increase in survival during 1990 to 1992, the neonatal and early childhood outcomes of the survivors were unchanged. Physicians and parents anticipating the delivery of extremely low birth weight infants must be aware of these outcomes to make informed decisions as to the advisability of aggressive care at birth and thereafter.
Status Epilepticus in Children With Epilepsy: The Role of Antiepileptic Drug Levels in Prevention
Authors: Maytal Joseph , Novak Gerald , Ascher Catherine , Bienkowski Robert
Published: December 2021

Objectives. To determine the association between subtherapeutic antiepileptic drug (AED) levels or AED withdrawal and status epilepticus (SE) in children with epilepsy.

Methods. We studied the AED levels at the time of SE in 51 consecutive children with epilepsy. Information about prior AED levels, possible etiology of seizures, and acute precipitants was extracted from medical records.

Results. The mean age at the time of SE was 5.7 years (range, 3 months through 18 years). Forty-three patients had history of remote insult, five had history of progressive encephalopathy, and three patients were classified as idiopathic. At the time of SE all AED levels were therapeutic in 34 (66%) patients and at least one level was therapeutic in 42 (82%) patients. All levels were subtherapeutic in 9 (18%) patients. Four patients had their AED reduced or discontinued less than 1 week before SE. Twelve patients with therapeutic AED levels on their most recent clinic visit had at least one subtherapeutic level at the time of SE. Eight (16%) patients were febrile and one was hyponatremic. Of the 51 patients, 31 (61%) had no obvious explanation for the development of SE, as all known AEDs were therapeutic and there were no known acute insults.

Conclusions. Neurologically abnormal children with preexisting epilepsy are at high risk for development of SE despite having therapeutic AED levels at that time. Acute precipitants of SE, such as fever or AED withdrawal, may play a role in inducing SE only in a minority of patients.
Commentary: A Controlled Trial of Nurse Practitioners in Intensive Care
Authors: HARPER RITA G. , SIA CONCEPCION G. , SCHLESSEL JERROLD S.
Published: December 2021

In this issue of Pediatrics (pages 1143-1148), there is an article by Mitchell-DiCenso et al entitled "A Controlled Trial of Nurse Practitioners in Neonatal Intensive Care." The clinical nurse specialists/nurse practitioners (CNS/NPs) as well as the controls (pediatric residents) were supervised by neonatologists or neonatal trainees. The CNS/NPs provided care for their patients during the day while the residents provided 24 hours per day care for their patients and evening and night coverage for the CNS/NPs' patients. The authors measured diverse outcome variables including mortality, neonatal complications, quality of care, parental satisfaction, costs, etc, and concluded that the CNS/NPs and pediatric residents were similar with respect to all tested measures of performance.
Thyroiditis in Children
Authors: Bachrach Laura K. , Foley Thomas P.
Published: December 2021

Thyroiditis ranks with diabetes as the most common of the endocrine disorders of childhood. The term encompasses all forms of thyroid gland inflammation and infection, although chronic lymphocytic thynoiditis is overwhelmingly the most frequent. Thyroiditis may appear as a mass in the neck of an asymptomatic child or it may be a painful, erythematous goiter in a sick child. The affected thyroid gland may be small on large, with varying degrees of dysfunction. Most commonly, thyroiditis causes euthyroid function, although the disease process can result in transient or permanent thyroid dysfunction. The causes of thyroiditis in childhood, as well as the less common thyroid disorders in the differential diagnosis of goiter, are listed in Table 1. Thyroid physiology and pathophysiology will be discussed briefly to explain the rationale for diagnostic studies and treatment strategies. The more recent diagnostic techniques and therapeutic controversies regarding thyroiditis will be included. The goal is to provide the clinician with renewed awareness of this most common pediatric problem.

THYROID PHYSIOLOGY

Thyroid hormone production is regulated by a classical negative feedback system (Fig 1). Hypothalamic thyrotropin-releasing hormone (TRH) stimulates the synthesis and secretion of thyroid-stimulating hormone (TSH) from the pituitary. TSH, in turn, stimulates production and release of thyroxine (T4) and triiodothyronine (T3).
Pediatric Bone Marrow Transplantation
Authors: Yeager Andrew M.
Published: December 2021

Bone marrow transplantation is a high-visibility, high-technology discipline with a growing list of potentially curative applications in neoplastic, hematologic, immunologic, and genetic diseases of children. The clinical problems experienced by children who have received bone marrow grafts involve pediatricians in both general and subspecialty practice and require a working knowledge of the applied immunobiology of bone marrow transplantation. As the transplantation procedure has evolved from a research tool to an established therapeutic modality, collaboration between basic scientists and clinicians has led to a greater understanding of the pathophysiology of the immunobiologic events that occur after allogeneic bone marrow transplantation and, thus, to improvements in the clinical care of transplant recipients. As its applications in pediatric medicine grow, bone marrow transplantation presents additional challenges for the future: expansion of the allogeneic donor pool, use of more effective or aggressive preparative regimens and autologous bone marrow-purging strategies, more effective prevention and treatment of graft-versus-host disease, and development of gene-replacement therapy by infusion of modified autologous bone marrow cells.
Quality Improvement: Buzz Words or Boon?
Authors: Bergman David A.
Published: December 2021

Background

Assessment of quality in health care has a long history, dating back to the works of E.A. Codman, who wrote in 1914 about improving the quality of care by evaluating the results of treatments.1 These views were not widely accepted at the time. Codman experienced considerable frustration in persuading his colleagues to keep accurate records and note the outcomes of their treatment. Ultimately, he resigned from the staff of the Massachusetts General Hospital and formed his own hospital, where he diligently kept records of his surgical procedures and patients' outcomes. Codman's ideas concerning outcome-based quality improvement were not considered seriously again until the 1980s. In the interim, many physicians regarded the quality of care they provided to be high, but they could neither define nor measure it exactly. This attitude toward quality perhaps is illustrated by a quotation from Pirsig's Zen and the Art of Motorcycle Maintenance: "Quality.... you know what it is, yet you don't know what it is....But when you try to say what quality is, apart from the things that have it, it all goes poof! There is nothing to talk about. But if you can't say what quality is, how do you know what it is, or how do you know that it even exists?"2
Consultation with the Specialist
Authors: Seidel James
Published: December 2021

Case Report

Bobbi, a 5-year-old, was playing "catch" on the lawn of his surburban home. When he went to fetch the ball that had rolled into the street, he was struck by an automobile traveling about 25 miles per hour. Witnesses reported that Bobbi's body was lifted up by the car and thrown about 12 feet onto the pavement. A neighbor responded immediately and noted that Bobbi was responsive to verbal commands and had a large bump on the front of his head and a swollen right thigh. The Emergency Medical Services System was activated, and within 10 minutes he was transported to the emergency department at the local community hospital.

Bobbi was in obvious pain but was awake and responded to questions. He knew his sister's and teachers' names, but did not remember being struck by the car. His vital signs were: respirations 35/min; pulse, 100/min; blood pressure, 98/68 mm Hg; and temperature, 36.5°C. Physical examination was remarkable for a large hematoma on the right frontal and parietal areas of the skull and a swollen tender right thigh.

Bobbi's spine was normal upon physical examination, and the neurologic examination was normal except for some retrograde amnesia. There was no spinal swelling or tenderness, and cervical spine radiographs were normal
Allergic Contact Dermatitis in Children
Authors: Hogan Peter A. , Weston William L.
Published: December 2021

Definition

Allergic contact dermatitis (ACD) is an inflammatory reaction of the skin that follows percutaneous absorption of antigen from the skin surface and recruitment of previously sensitized, antigen-specific T lymphocytes into the skin.

Epidemiology

In the pediatric age group, ACD can involve either sex and manifest as early as the first week of life. A recent review of several European and US studies found that ACD may account for up to 20% of cases of dermatitis in the 0- to 14-year-old age group. Although the incidence and prevalence of the disease in the general pediatric population is unknown, epicutaneous patch testing of randomly selected and otherwise healthy children revealed that 13% to 20% were allergic to one or more common antigens, suggesting that at least 20% of children in the general population theoretically are at risk of developing ACD. When one considers poison ivy or poison oak as contact allergens prevalent in certain areas of North America, the likelihood of allergic contact dermatitis may be much higher. Pediatricians should recognize that children are sensitized to contact allergens early in life, with most children being sensitized by age 5 years. The allergens most commonly responsible for allergic contact dermatitis in North American children are listed in Table 1.
Immunization for Hepatitis B Infection: Interest, Information, and Initiative?
Authors: Hall Caroline Breese
Published: December 2021

Concerns and confusion have risen over the recent recommendations for universal immunization to prevent infection with hepatitis B virus (HBV) published by the American Academy of Pediatrics (AAP)1 and the Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control (CDC).2 Both of these recommendations, collaboratively developed, recommend universal immunization of infants against HBV as well as the continued previous strategies of screening all pregnant women for HBsAg positivity and immunizing all high-risk groups. The AAP further recommends that all adolescents be immunized in recognition of the increased risk and rate of acquiring HBV in this age group.
Gastrointestinal Endoscopy in Infants and Children
Authors: Wyllie Robert , Kay Marsha H.
Published: December 2021

Introduction

The earliest gastrointestinal (GI) endoscopies were performed in the late 1880s by using rigid instruments to examine the esophagus and rectum. The semiflexible gastroscope was developed in the early 1930s by Schindler and Wolf, and fiberoptic endoscopes were popularized in the late 1960s and early 1970s. The first small-diameter instrument used for esophagogastroduodenoscopy (EGD) in a child was a fiberoptic bronchoscope. Video endoscopy has only developed over the past 2 decades, with the first mass-produced video instruments introduced in the 1980s. Parts or all of the procedure can be recorded for later review. Pediatric GI endoscopists can perform most of the endoscopic techniques of their adult counterparts. The referring physician and endoscopist should be familiar with the risks and benefits of endoscopy as well as clinical situations in which it is most useful.

Personnel

Specially trained pediatric endoscopy assistants are an important component of the endoscopy team. Preprocedure anxiety may be reduced by a physician, nurse, or play therapist explaining the procedure to the patient. One assistant can hold and reassure the child throughout the procedure while a second can help to obtain and process tissue and assist with other equipment and patient monitoring.

Physicians performing GI endoscopy on infants and children should have completed a pediatric gastroenterology fellowship or have experience with pediatric gastrointestinal diseases and adequate training in pediatric endoscopy.
Consultation with the specialist
Authors: Young Richard S.K.
Published: December 2021

History and Physical Examination

More than 10 000 individuals suffer spinal cord injury each year. This article will focus on those mass lesions of the spinal cord that should prompt neurosurgical consultation: epidural abscesses, neoplasms, and hematomas. The presence of pain and spinal cord dysfunction (paralysis, loss of sphincters) makes neurosurgical consultation mandatory.

Because of the anatomy of the spinal cord, it has several classical patterns of involvement (see Table). When obtaining a history, inquire about pain over the spine or pain that radiates down the legs. The presence of paresthesiae suggests involvement of the posterior roots or posterior columns of the spinal cord. Inquire whether the patient's sphincter function is normal. Difficulty in ambulation or refusal to walk are hallmarks of spinal cord disease.

Observe the patient's gait for limp, waddling, or circumduction. Inspect the spine carefully for scoliosis or for neural tube defects. Examine the skin for signs of neurologic disease (café au lait spots, axillary freckles, cutaneous hemangiomas). If cutaneous hemangiomas are present over the spine, auscultate for the presence of arteriovenous malformations. Percuss the spine to elicit pain suggestive of abscesses or radicular disease.

Infections of the Spinal Cord

Case Report: A 4-year-old child who had been adopted from a Korean orphanage was brought to her pediatrician for evaluation of a limp.
Persistent Vomiting
Authors: Ramos Asuncion G. , Tuchman David N.
Published: December 2021

Vomiting is forceful expulsion of gastric contents through the mouth. The diagnostic challenge for the clinician is to determine whether vomiting occurs as part of a benign, self-limited process or whether it is the presenting symptom of a major underlying disorder. The following discussion provides an overview of the pathophysiology of vomiting, the major conditions that cause chronic vomiting, and principles of management.

Definitions

Vomiting is a highly integrated, chiefly somatic motor event that often is preceded by nausea, increased salivation, and retching. Vomiting is distinct from regurgitation, which is defined as passive movement of gastric contents into the esophagus. Regurgitation often is considered synonymous with gastroesophageal reflux (GER), although vomiting, too, may be a symptom of reflux. Vomiting and regurgitation can be distinguished through a careful history. This difference is important to establish because conditions associated with chronic regurgitation generally are less severe than those that occur with chronic vomiting.

During fluoroscopy, regurgitation appears as a "to-and-fro" movement of contrast material from the stomach into the esophagus. In contrast, vomiting is seen as an active phenomenon and involves simultaneously occurring events. There is a rapid increase in intra-abdominal and intragastric pressure that occurs secondary to contraction of the diaphragm and the abdominal muscles.
Quality Improvement: An ACQIP Exercise on Vaccine Administration—Part 1
Authors: Smith-Ross Shannon ,   Staff of the Division of Quality Care
Published: December 2021

As part of Pediatrics in Review's ongoing focus on quality improvement, we present for the use of our readers this self-assessment exercise taken from the American Academy of Pediatrics' Ambulatory Care Quality Improvement Program (ACQIP). ACQIP is an educational program for pediatricians that embodies the concept of continuous quality improvement. It has been implemented successfully in physicians' offices, health maintenance organizations, and hospitals.

Currently, more than 2000 physicians worldwide are enrolled in ACQIP. The program is designed to help pediatricians evaluate their practices by comparing themselves with other physicians in similar practices and communities. Pediatricians in groups can use ACQIP to analyze practice variations within the group. Three aspects of care are addressed:

• Practice management

• Delivery of preventive care

• Patient satisfaction

Each year, a theme is selected. In 1992-1993, the first year, the theme was immunizations. The 1993-1994 program focused on telephone management, developmental assessment, and management of asthma. ACQIP is being used by the American Academy of Pediatrics (AAP) as a vehicle to disseminate and implement its new practice parameters on asthma, neonatal hyperbilirubinemia, otitis media, gastroenteritis, head trauma, febrile seizures, and urinary tract infections. This year's exercises (September 1994 to August 1995) will be on otitis media and hyperbilirubinemia and will be based on the parameters.