bluuebunny/crossref_metadata_2025 huggingface dataset:
Why Would You Remove Half a Brain? The Outcome of 58 Children After Hemispherectomy—The Johns Hopkins Experience: 1968 to 1996
Authors: Vining Eileen P. G. , Freeman John M. , Pillas Diana J. , Uematsu Sumio , Carson Benjamin S. , Brandt Jason , Boatman Dana , Pulsifer Margaret B. , Zuckerberg Aaron
Published: August 2004

Purpose. To report the outcomes of the 58 hemispherectomies performed at Johns Hopkins between 1968 and January 1996.

Methods. Charts were reviewed of the 58 hemispherectomies performed at Johns Hopkins Medical Institutions by the Pediatric Epilepsy Group during the years 1968 to 1996. Twenty-seven operations were done for Rasmussen's syndrome, 24 operations for cortical dysplasias/hemimegalencephalies, and 7 for Sturge-Weber syndrome or other congenital vascular problems. Seizure control alone did not seem to adequately describe the outcomes of the procedure. Therefore, a score was constructed that included seizure frequency, motor disability, and intellectual handicap. This burden of illness score better described the child's handicap before and after surgery.

Results. Perioperative death occurred in 4 out of 58 children. Of the 54 surviving children, 54% (29/54) are seizure-free, 24% (13/54) have nonhandicapping seizures, and 23% (12/54) have residual seizures that interfere to some extent with function. Reduction in seizures was related to the etiology of the unilateral epilepsy. Eighty-nine percent of children with Rasmussen's, 67% of those with dysplasias, and 67% of the vascular group are seizure-free, or have occasional, nonhandicapping seizures. All operations were considered by the parents and the physicians to have been successful in decreasing the burden of illness. In 44 the procedure was very successful, in 7 it was moderately successful, and in 3 it was minimally successful. Success was related to the etiology, and early surgery was preferable.

Conclusion. Hemispherectomy can be a valuable procedure for relieving the burden of seizures, the burden of medication, and the general dysfunction in children with severe or progressive unilateral cortical disease. Early hemispherectomy, although increasing the hemiparesis in children with Rasmussen's syndrome, relieves the burden of constant seizures and allows the child to return to a more normal life. In children with dysplasias, early surgery can allow the resumption of more normal development.
End-of-Life Care in Cystic Fibrosis
Authors: Robinson Walter M. , Ravilly Sophie , Berde Charles , Wohl Mary Ellen
Published: August 2004

Objective. End-of-life clinical care in cystic fibrosis (CF) differs substantially from terminal care in childhood cancer. To examine this difference, we reviewed the medical care of a cohort of CF patients treated at Children's Hospital, Boston, to document the use of preventive, therapeutic, and palliative care in the month preceding death.

Patients. We reviewed the medical records of 44 patients older than 5 years who died of CF-related respiratory failure for the years 1984 to 1993.

Results. Thirty-eight patients (86%) received opiates for the treatment of severe dyspnea and pain; the duration of opiate use varied from less than 1 hour to greater than 1 month. The dose of opiates varied from less than 5 mg per hour to greater than 30 mg per hour. Thirty-three patients (75%) continued to receive intravenous antibiotics in the last 12 hours of life; 32 (72%) continued to receive preventive or therapeutic oral medications in the last 12 hours of life. All patients were designated as do not resuscitate at the time of death; 43 of the patients died in the hospital with 1 patient dying at home under hospice care.

Conclusions. The model of comfort care developed in childhood cancer does not adequately describe the combination of preventive, therapeutic, and palliative care given at the end of life for CF at our institution. The majority of CF patients continued to receive intravenous antibiotics and/or oral vitamin preparations while being treated with opiates for terminal pain and dyspnea. Small doses of opiates seem to be effective in the treatment of the pain and dyspnea at the end of life in CF.
Strategies to Increase Adherence With Tuberculosis Test Reading in a High-risk Population
Authors: Cheng Tina L. , Ottolini Mary C. , Baumhaft Kalanit , Brasseux Cynthia , Wolf Muriel D. , Scheidt Peter C.
Published: August 2004

Objective. To determine the most effective strategy to encourage adherence with tuberculosis test reading in a high-risk population.

Design. Prospective randomized controlled trial.

Setting/Participants. Consecutive sample of 627 children ages 1 to 12 years due for a tuberculosis (TB) test in an urban children's hospital outpatient department. One child per family was enrolled.

Intervention. All families received education regarding the importance of skin testing for TB and the need for follow-up, and written and verbal instructions regarding test reading. Families were randomly assigned to one of five strategies for follow-up TB test reading at 48 to 72 hours: 1) routine verbal and written instructions, 2) reminder phone call, 3) transportation tokens and toy on return, 4) withholding of school forms until time of reading and need to repeat TB test if not timely read, 5) parents taught to read induration with nurse home visit. Those who did not have tests read at 48 to 72 hours by a trained professional were phoned 1 week later.

Results. The five groups did not differ with regard to TB risk factor score, maternal education, transportation source, or perceived importance of TB testing. Before the study the follow-up rate of TB test reading by a trained professional was 45%. Reading rates in this study were 58%, 70%, 67%, 70%, and 72% for groups 1 to 5, respectively. In group 4, only 39% had school forms to be completed and their adherence rate was 84% (53/63). Compared to group 1, the only statistically significant improvement was in group 4, especially for those who needed school forms completed, and in group 5. Those not adhering in groups 1 to 4 did not differ from returnees with regard to TB risk factors, maternal education, transportation, or perceived importance of testing. The most common reasons for failing to return included forgetfulness, transportation, and time constraints. Group 5 was stopped early because of difficulty with nurse visits (N = 98). When told of the nurse visit, 9% (9/98) families could not find a time for the visit. Seventeen percent (17/98) were visited but the child was not home, and 7% (7/98) were not visited because of a nurse scheduling problem.

Conclusions. In a high-risk population, adherence with TB test reading is poor. However, education and return of school forms at reading time can significantly improve adherence. Although requiring larger investment in resources, visiting nurses may also aid in test reading.
Bedsharing Promotes Breastfeeding
Authors: McKenna James J. , Mosko Sarah S. , Richard Christopher A.
Published: August 2004

Objective. Because breastfeeding is thought to be protective against sudden infant death syndrome (SIDS), environmental or child care factors that promote breastfeeding might reduce infant vulnerability to SIDS. The effect of mother-infant bedsharing on nocturnal breastfeeding behavior was studied in 20 routinely bedsharing and 15 routinely solitary sleeping Latino mother-infant pairs when the infants were 3 to 4 months old.

Methodology.  All pairs were healthy and exclusively breastfeeding at night. The videotape portion of all-night laboratory polysomnographic studies was used for the analyses. For each pair, an adaptation night was followed by one night each of bedsharing and solitary sleeping.

Results. The most important finding is that when tested in their usual sleeping conditions, routinely bedsharing infants breastfed approximately three times longer during the night than infants who routinely slept separately: this reflected a two-fold increase in the number of breastfeeding episodes and 39% longer episodes. Breastfeeding was also facilitated on the bedsharing night relative to the solitary night within the routinely bedsharing group: the number and total duration of breastfeeding episodes were significantly larger on the bedsharing night.

Conclusions. We suggest that, by increasing breastfeeding, bedsharing might be protective against SIDS, at least in some contexts. Furthermore, maternal reproductive physiology could be impacted because nursing frequency affects ovulation. This is the first study to directly measure nocturnal breastfeeding behavior in any cultural group.
Babywalker-related Injuries Continue Despite Warning Labels and Public Education
Authors: Smith Gary A. , Bowman Mary Jo , Luria Joseph W. , Shields Brenda J.
Published: August 2004

Objective. To describe the epidemiology of babywalker-related injuries to children treated in a pediatric emergency department despite current prevention efforts, and to investigate the beliefs of parents regarding babywalker use.

Design. A descriptive study of a consecutive series of patients.

Setting. The emergency department of a large, academic children's hospital.

Participants. Children treated for babywalker-related injuries during the 3-year period of March 1993 through February 1996.

Results. There were 271 children treated for babywalker-related injuries. The mean age was 9.2 months, and 62% of patients were boys. Ninety-six percent of children were injured when they fell down stairs in their babywalker. The number of stairs that a child fell down was significantly associated with skull fracture and admission to the hospital, and a fall down more than 10 stairs had a relative risk (RR) of skull fracture = 3.28 (95% confidence interval, 1.35 < RR < 7.98). There were 159 children with contusions/abrasions (58.6%), 35 concussions/head injuries (12.9%), 33 lacerations (12.2%), 26 skull fractures (9.6%), 9 epistaxis (3.3%), 4 nonskull fractures (1.5%), 4 avulsed teeth (1.5%), and 1 burn (0.4%). Three of the skull fractures were depressed, and three also had accompanying intracranial hemorrhage. Ten patients (3.7%) were admitted to the hospital, and all had skull fractures resulting from falls down stairs. Supervision was present in 78% of cases, including supervision by an adult in 69% of cases. Forty-five percent of families kept the walker, and 32% used the walker again for the study patient or another child after the injury episode. Fifty-nine percent of parents acknowledged that they were aware of the potential dangers of babywalkers before the injury event. Fifty-six percent of parents favored a national ban on the sale of walkers, and 20% were opposed.

Conclusion. Despite the currently used prevention strategies, including adult supervision, warning labels, care giver education programs, and stairway gates, serious injuries associated with babywalkers continue to occur to young children. The US Consumer Product Safety Commission should promulgate a rule, similar to the voluntary standard adopted in Canada, regarding design requirements for babywalkers that will prevent their passage through household doorways at the head of stairs. The manufacture and sale of mobile babywalkers that do not meet this new standard should be banned in the US. A recall or trade-in campaign should be conducted nationally to decrease the number of existing babywalkers.
Auxiliary Liver Transplant in Fulminant Failure
Authors: Rosenthal Philip , Roberts John P. , Ascher Nancy L. , Emond John C.
Published: August 2004

Fulminant hepatic failure (FHF) is defined as a syndrome of acute liver failure with the development of hepatic encephalopathy and severe hypoprothrombinemia occurring within 2 months of the onset of symptoms or jaundice in a person without preexisting liver disease.1 Total orthotopic liver transplantation (OLTX) is a lifesaving therapeutic option for patients with FHF, but currently requires lifelong immunosuppression to maintain the graft.2 Auxiliary partial orthotopic liver transplantation (A-OLTX) is a procedure whereby only a portion of the native liver is removed, and the remainder of the native liver is left in situ.3 A-OLTX provides temporary support until the native liver recovers and immunosuppression can be withdrawn.

We describe the successful application of emergency A-OLTX in a young girl who accidentally ingested Amanita phalloidesmushrooms and developed FHF.
Escalator-related Injuries in Children
Authors: Platt Shari L. , Fine Jeffrey S. , Foltin George L.
Published: August 2004

Objective. Escalator-related trauma is uncommon but can cause significant injury. This study reviewed escalator-related injuries in children to determine risk factors, types of injuries, medical interventions, and long-term outcomes.

Design and Setting. Retrospective clinical patient series, Municipal Hospital Pediatric Emergency Service.

Participants. All children less than 18 years of age who presented to the Pediatric Emergency Service with an escalator-related injury from August 1990 through February 1995.

Methods. We reviewed the chart and interviewed the parent of each child by telephone. We collected the following information: age, gender, child's supervision and activity while on the escalator, escalator location, direction of motion, presence of escalator defects, nature and extent of injury, medical interventions, and outcome.

Results. Twenty-six children had escalator-related injuries. The average age was 6 years (range, 2–16). Thirteen children (50%) were 2 to 4 years old. There were 15 (57%) boys. Eighteen children (69%) were accompanied by an adult. All children 7 years and younger were accompanied by an adult; however, 50% were not holding the hand of their guardian. Eight children (31%) were injured while riding improperly, ie, walking, running, playing, or sitting on the escalator, and among these, all who were standing fell down before the injury. Six (23%) children were injured while stepping off the escalator. Of 9 children less than 4 years old, 7 (78%) were riding the escalator properly. Of 9 children 4 years or older, only 3 (33%) were riding properly. Circumstances of injury included falling down with subsequent blunt trauma, falling down with subsequent entrapment of an extremity, and entrapment of an extremity not related to falling down. Locations of entrapment were between two steps, between a step and the side-rail, and between the last step and the comb plate. Twenty-one (81%) injuries occurred in rail or subway stations. Eight escalators were reported to have functional or structural problems.

Seventeen (65%) children sustained lower extremity injuries and 8 (31%) sustained upper extremity injuries. Injuries included lacerations, avulsions and degloving injuries of the extremities, tendon and nerve lacerations, and digit fractures and amputations. Thirteen (50%) children were admitted to the hospital for operative management; the average length of hospitalization was 13 days (range 1–29). Four children (15%) suffered significant functional loss, and 12 (46%) sustained permanent cosmetic deformities.

Conclusion. Children are at risk for sustaining severe injuries on escalators. Young age, inadequate adult supervision, improper activity while riding on the escalator, and escalator-related mechanical problems all increase the risk of injury. Public and parent education directed toward escalator safety issues may help to reduce escalator-related injuries in children.
Beyond Dorsal Penile Nerve Block: A More Humane Circumcision
Authors: Stang Howard J. , Snellman Leonard W. , Condon Lawrence M. , Conroy Mary Margaret , Liebo Rhoda , Brodersen Laurie , Gunnar Megan R.
Published: August 2004

Objective. To explore techniques that can be utilized in addition to the dorsal penile nerve block (DPNB) to further reduce the neonate's stress and pain from routine circumcision, and thus make the procedure more humane.

Setting. Level 1 nursery at a community hospital.

Subjects. Eighty healthy, term, newborn male infants scheduled for routine neonatal circumcision.

Study Design. Prospective and randomized; double blind and placebo controlled for the study solutions.

Methods. Four statistically similar groups of 20 were studied. The control group included infants circumcised using: a) a rigid plastic restraint board; b) standard DPNB; and c) a pacifier dipped in water to comfort the infant. Each study group differed from the controls in one variable including: 1) using a specially designed, physiologic circumcision restraint chair; 2) pH buffering of lidocaine hydrochloride used for DPNB; and 3) offering a pacifier dipped in a 24% sucrose solution during the DPNB and circumcision. Behavioral observations were recorded and compared for each group starting before the injection of lidocaine hydrochloride and continuing through the completion of the circumcision. Plasma for cortisol levels were collected 30 minutes after the circumcision.

Results. Neonates circumcised on the new restraint chair showed a significant decrease in distress scores (>50%) compared with the control group on the rigid molded-plastic restraint. The pacifier dipped in sucrose had a distress-reducing effect during both the post-DPNB injection and circumcision periods. The infants who were injected with the buffered lidocaine showed no differences in distress from the controls. The plasma cortisol levels were not significantly affected by any additional technique and were comparable to the levels previously reported.

Conclusions. When neonatal circumcisions are performed routinely, they should be done as humanely as possible. This study demonstrates that, when used in conjunction with DPNB, a pacifier dipped in 24% sucrose and a more comfortable, padded, and physiologic restraint can be useful in decreasing distress and pain.
Evolution in the Recognition of Infantile Hypertrophic Pyloric Stenosis
Authors: Hulka Frieda , Campbell Timothy J. , Campbell John R. , Harrison Marvin W.
Published: August 2004

Purpose. To analyze changes in the clinical condition at presentation and methods of establishing the diagnosis of infantile hypertrophic pyloric stenosis (IHPS).

Methods. Retrospective review of patients who underwent pyloromyotomy (PM) for suspected IHPS at two institutions from 1969 through 1994 was performed. For the purposes of comparison, the population was divided into five equal time periods.

Results. Over the 25-year period, 901 infants underwent PM. Patients presented at a younger age, weighed more, and had a shorter length of illness in the most recent time period. Hypochloremic alkalosis was found half as frequently in the most recent time period compared to the earliest group. A palpable pyloric tumor was present in 79% of patients in the earliest time period compared with 23% in the most recent time period. Sixty-one percent of patients in the earliest group and 96% in the latest group underwent an imaging study, reflecting the referring physician's evaluation before referral to the surgeon.

Conclusions. Currently, patients with IHPS less frequently present with the clinical hallmarks of the disease. The use of imaging studies to establish the diagnosis has become common practice. The result has been the diagnosis of IHPS before alkalosis has developed, a shorter clinical course, less morbidity, and a shorter postoperative hospital stay.
Food Intakes of US Children and Adolescents Compared With Recommendations
Authors: Muñoz Kathryn A. , Krebs-Smith Susan M. , Ballard-Barbash Rachel , Cleveland Linda E.
Published: August 2004

Objectives. To determine the proportion of youth meeting national recommendations for food group intake and to identify food intake patterns.

Design. The US Department of Agriculture's 1989–1991 Continuing Surveys of Food Intakes by Individuals were used to estimate food intake. Intake was determined from 3 days of diet by disaggregating foods into their component ingredients and using weights that correspond to servings.

Participants. The sample included 3307 youth, 2 to 19 years of age, living in the 48 conterminous United States.

Main Outcome Measures. Mean number of servings and percentage of individuals meeting national recommendations for food group intake according to demographic characteristics, patterns of intake, and nutrient profiles associated with each pattern.

Results. Mean numbers of servings per day were below minimum recommendations for all food groups except the dairy group (ages 2 to 11). Percentages of youth meeting recommendations ranged from ∼30% for fruit, grain, meat, and dairy to 36% for vegetables. Sixteen percent of youth did not meet any recommendations, and 1% met all recommendations. The pattern of meeting all recommendations resulted in nutrient intakes above the recommended dietary allowances and was high in fat. Conversely, meeting none of the recommendations resulted in intakes well below the recommended dietary allowances for some nutrients. Total fat and added sugars averaged 35% and 15% of energy, respectively, and levels were similar among most demographic groups.

Conclusion. Children and teens in the United States follow eating patterns that do not meet national recommendations. Nutrition education and intervention are needed among US children.
Parents Can Dose Liquid Medication Accurately
Authors: McMahon Shawn R. , Rimsza Mary E. , Bay R. Curtis
Published: August 2004

Objective. To determine whether parental errors in dosing liquid medication can be decreased through education.

Design. Randomized convenience sample stratified to three study groups.

Setting. General pediatric clinic, largely indigent and Latino.

Patients. A total of 45 English-speaking and 45 Spanish-speaking children diagnosed with otitis media and treated with an antibiotic suspension.

Intervention. Group 1 patients received the prescription and verbal instructions. Group 2 patients received the prescription and a syringe, then the correct dose was demonstrated. Group 3 patients received the prescription, a syringe with a line marked at the correct dose, and a demonstration. After returning from the pharmacy, parents administered the medication under observation. Parents in group 1 used a dispensing device similar to that planned for home use. The other groups used the syringe. After observation but before discharge, everyone received a syringe with a line marked at the correct dose. Patients were seen again at ∼1 month, and parents demonstrated how much medication they had administered.

Main Outcome Measure. Percent of parents who administered the correct dose.

Results. Patients in group 1 received between 32% and 147% of the correct dose, with only 11 of 30 (37%) receiving the correct dose (±0.2 mL). In group 2, 25 of 30 (83%) parents administered the correct dose, and in group 3, 30 of 30 (100%) gave the correct dose. Simultaneous logistic regression indicated that accuracy of dosage differed across instructional groups and language. At follow-up, 23 of 26 parents demonstrated the correct dose.

Conclusion. Education can decrease medication dosing errors made by both Spanish-speaking and English-speaking parents. Effectiveness was also shown at follow-up.
Outpatient Management Practices Associated With Reduced Risk of Pediatric Asthma Hospitalization and Emergency Department Visits
Authors: Lieu Tracy A. , Quesenberry Charles P. , Capra Angela M. , Sorel Michael E. , Martin Kathleen E. , Mendoza Guillermo R.
Published: August 2004

Objectives. Effective outpatient care is believed to prevent hospitalization and emergency department (ED) visits resulting from childhood asthma. The aim of this study was to suggest priority areas for intervention by identifying outpatient management practices associated with the risk of these adverse outcomes in a large population.

Methods. This case-control study included children aged 0 to 14 years with asthma who were members of a regional health maintenance organization. Cases were children undergoing either a hospitalization or an ED visit for asthma during the study period. Control subjects were children with asthma without a hospitalization or an ED visit during the study period who were matched to patients on age, gender, and number of asthma-related hospitalizations in the past 24 months. Data on provider and parent asthma management practices were collected using chart review, closed-ended telephone interviews with parents, and computerized use databases. Multivariate analyses were conducted using conditional logistic regression models.

Results. Data were collected on 508 cases and 990 control subjects. A total of 43% of cases were reported by their parents to have moderately severe or severe asthma, compared with 20% of control subjects. Parents of cases with hospitalization were less likely than control subjects to have a written asthma management plan (44% vs 51%) and to report washing bedsheets in hot water at least twice a month (77% vs 86%). Cases with hospitalization were more likely to have a nebulizer (74% vs 56%).

In the final multivariate model, race/ethnicity was not associated with having had either a hospitalization or an ED visit, as was lower socioeconomic status. Having a written asthma management plan [odds ratio (OR): 0.54; 95% confidence interval (CI): 0.30, 0.99] and washing bedsheets in hot water at least twice a month (OR: 0.45; 95% CI: 0.21, 0.94) were associated with reduced odds of hospitalization. Having a written asthma management plan (OR: 0.45; 95% CI: 0.27, 0.76) and starting or increasing medications at the onset of a cold or flu were associated with reduced odds of making an ED visit.

Conclusions. Practices that support early intervention for asthma flare-ups by parents at home, particularly written management plans, are strongly associated with reduced risk of adverse outcomes among children with asthma.
Apnea Frequently Persists Beyond Term Gestation in Infants Delivered at 24 to 28 Weeks
Authors: Eichenwald Eric C. , Aina Abimbola , Stark Ann R.
Published: August 2004

Background. Apnea of prematurity remains among the most commonly diagnosed conditions in the Newborn Intensive Care Unit and may prolong hospital stays in some infants. Because survival of extremely premature infants has improved markedly, the natural history of apnea in this population needs to be reassessed.

Objective. To document the natural history of recurrent apnea and/or bradycardia events in infants delivered at 24 to 28 weeks' gestation.

Methods. Medical records of all infants delivered at 24 to 28 weeks' gestation admitted to the Brigham and Women's Hospital Newborn Intensive Care Unit between January 1989 and March 1994 were reviewed to document the clinical course of apnea of prematurity. Subjects were included in the study sample if they were discharged home from the Brigham and Women's Hospital or after transfer to an affiliated hospital. Recordings of apnea and/or bradycardia events were based on nursing observations of monitor alarms and assessment of the infant's condition.

Results. Of 457 eligible infants, 226 were included in the study sample and stratified by gestational age at birth assigned by the attending neonatologist. The time to resolution of recurrent apnea/bradycardia events was longer with lower gestational age at birth. Apnea/bradycardia events were frequently observed beyond 36 weeks' postconceptional age in all gestational age groups. The incidence of apnea persisting beyond 38 weeks postconceptional age was significantly higher in the 24- to 27-week infants combined compared with the 28-week infants.

Conclusions. Apnea of prematurity frequently persists beyond term gestation in infants delivered at 24 to 28 weeks' gestational age. These persistent apnea and/or bradycardia events may contribute to prolonged hospitalization. Programs to promote earlier discharge of premature infants should take into account the variability in resolution of apnea and specifically address management of persistent apnea.
Purpuric Phototherapy-induced Eruption in Transfused Neonates: Relation to Transient Porphyrinemia
Authors: Paller Amy S. , Eramo Lynne R. , Farrell Elaine E. , Millard Dietra D. , Honig Paul J. , Cunningham Bari B.
Published: August 2004

Objective. Blue light phototherapy is commonly administered to neonates as treatment of indirect hyperbilirubinemia, often in conjunction with blood transfusions to treat hemolytic anemia. We observed a distinctive cutaneous complication of phototherapy in six neonates with hyperbilirubinemia.

Methodology. We studied the clinical and histologic characteristics of the eruption, as well as the porphyrin levels in affected neonates. Five of the patients had erythroblastosis fetalis; the other had profound anemia from twin–twin transfusion. All of the neonates developed purpuric patches at sites of maximal exposure to the phototherapy lights, with dramatic sparing at shielded sites within 24 hours after initiation of the phototherapy. On discontinuation of phototherapy, all eruptions cleared within 1 week. Examination of skin biopsy sections showed purpura without significant inflammation or keratinocyte necrosis. Plasma porphyrins (copro- and proto-) were elevated in the two patients in which they were assessed.

Conclusions. The distribution of the eruption in areas exposed to light and presence of circulating porphyrins suggest that porphyrinemia may underlie the light-induced purpuric eruption. Additional studies will be required to determine definitively the mechanisms of both the purpuric phototherapy-induced eruption and the development of increased blood porphyrin levels in these transfused neonates.
In Vivo Bone Lead Measurement in Suburban Teenagers
Authors: Hoppin Jane A. , Aro Antonio , Hu Howard , Ryan P. Barry
Published: August 2004

Objective. Bone represents a biologically active long-term storage site for lead, and bone lead data on teenagers are limited. Therefore, this study was designed to identify the distribution of bone lead in a teenage population and to explore the environmental and demographic factors associated with bone lead concentrations in young, nonoccupationally exposed subjects.

Design. A cross-sectional study of bone lead levels in high school students.

Participants. A total of 168 students at a suburban Boston high school. Subjects (90 boys, 78 girls) ranged in age from 13.5 to 19 years and included 40% nonwhite minorities. Of the 168 subjects, 45 lived in homes constructed before 1960. None of the participants reported a history of lead poisoning.

Outcome Measures. Tibial bone lead concentrations were measured in vivo for 60 minutes using K x-ray fluorescence. Lead exposure information was obtained by self-administered questionnaire.

Results. Point estimates of bone lead levels ranged from −7.15 to 14.23 μg lead/g bone mineral (μg/g), (mean, 4.0 μg/g; standard deviation, 4.4 μg/g). The reported measurement uncertainties accompanying each of the point estimates ranged from 2.56 to 9.01 μg/g (mean, 3.9 μg/g; standard deviation, 1.0 μg/g). Bone lead levels were not associated with the demographic factors of age, sex, or race. Additionally, current home conditions (housing age, traffic level) were not predictive of bone lead levels, even though these factors were predictive of in-home lead concentrations.

Conclusions. These results demonstrate that although bone lead levels are measurable in this age group, the common predictors of blood and bone lead concentrations are not explanatory for bone lead levels.
Cardiac Effects of a Competitive Road Race in Trained Child Runners
Authors: Rowland Thomas , Goff Donna , DeLuca Patricia , Popowski Barbara
Published: August 2004

Background. Animal studies and investigations of adult endurance athletes indicate a transient depression of myocardial function after prolonged high-intensity exercise.

Purpose. To determine whether a similar decrease is observed in child distance runners after a 4-km competitive road race.

Methods. Anthropometric measures, resting M-mode echocardiograms, maximal cycle exercise tests with estimation of cardiac output, and electrocardiograms were performed before a 4-km road race in nine run-trained boys (mean age, 12.2 years). Weight and resting echocardiogram and electrocardiogram were assessed immediately after the race. The entire test battery was repeated 24 hours later.

Results. Small but significant decreases in mean body weight and left ventricular end–diastolic dimension were observed immediately after the race, but there were no changes in shortening fraction. These findings are consistent with the effects of dehydration. Measurements returned to prerace values by 24 hours of recovery. Peak work capacity, maximal stroke volume, and maximal cardiac output were similar on prerace and 24-hour-postrace testing. No electrocardiographic abnormalities were observed.

Conclusions. No adverse cardiac effects were observed from a competitive 4-km road race in male child distance runners.
The Effect of Insurance Status on Likelihood of Neonatal Interhospital Transfer
Authors: Durbin Dennis R. , Giardino Angelo P. , Shaw Kathy N. , Harris Mary C. , Silber Jeffrey H.
Published: August 2004

Objective. To determine the effect of insurance status on the likelihood of interhospital transfer for neonates.

Design. Population-based retrospective cohort study.

Setting. All general acute care nonpediatric hospitals in the five counties of southeastern Pennsylvania.

Patients. Fifty-six thousand, seven hundred eighty-nine infants from 0 to 28 days of age admitted to or born in study hospitals between January 1 and December 31, 1991.

Intervention. None.

Main Outcome Measure. Transfer to another general or specialty acute care hospital.

Results. The incidence (95% confidence interval) of interhospital transfer was 1.69% (1.60, 1.78). Uninsured infants were nearly twice as likely [relative risk (RR) = 1.96 (1.67, 2.31)] to be transferred as commercially insured infants, even when adjusted for the effects of prematurity, severity of illness, and the level of neonatal intensive care unit in the referring hospital. Similarly, infants with Medicaid were more likely to be transferred [RR = 1.20 (1.01, 1.43)] than similar commercially insured neonates. Uninsured and publicly insured infants were also more likely to be born premature [RR 1.49 (1.39, 1.60)] than privately insured neonates, and were more likely to have both moderate [RR 1.11 (1.04, 1.23)] and high [RR 1.21 (1.11, 1.32)] illness severity on admission to the hospital than privately insured infants.

Conclusions. Neonates with no insurance and those with Medicaid coverage were more likely to be transferred than infants with private insurance. These results are consistent with those of other investigators who have studied financially motivated patient transfers— so-called patient dumping—in nonpediatric populations of patients. Our study may represent the first documentation of this phenomenon in a pediatric population. Our results are also consistent with those of other investigators who have examined the effect of insurance status on maternal interhospital transfer, thus providing further evidence for the existence of financially motivated transfers within regional systems of perinatal care. Future investigation into the effect of economic factors on variation in the utilization of transport services, and on how transfer influences ultimate patient outcome, is needed as managed care health systems become more widespread.
Tuberculosis Transmission Among Five School Bus Drivers and Students in Two New York Counties
Authors: Yusuf Hussain R. , Braden Christopher R. , Greenberg Abby J. , Weltman Andre C. , Onorato Ida M. , Valway Sarah E.
Published: August 2004

Objective. Between November 1994 and April 1995, more than 3300 students in 49 schools in two counties in New York were potentially exposed to five school bus drivers with tuberculosis. This investigation was carried out to determine the extent of transmission of Mycobacterium tuberculosis among students.

Methods. Components of the epidemiologic investigation included tuberculin skin-test screening and collection of demographic information for students exposed to a driver with tuberculosis, chest radiography and medical evaluation of individuals with positive skin tests, and DNA fingerprinting of M tuberculosis isolates. A positive skin test was defined as ≥10 mm induration, and a converter was an individual with an increase in reaction size of ≥10 mm in the past 2 years.

Results. The rates of positive skin tests were 0.8%, 0.3%, 9.9%, 1.1%, and 0.7% among US-born students exposed to drivers 1 through 5, respectively. The relative risk for a positive tuberculin skin test was significant only for students exposed to driver 3, and the only secondary case identified among students was exposed to driver 3. The DNA fingerprint patterns of isolates from drivers 3 and 4 matched.

Conclusion. There was no clear evidence of transmission ofM tuberculosis to students from drivers 1, 2, 4, or 5. However, evidence suggests that driver 3 transmitted M tuberculosis to students and another driver. Routine annual tuberculin skin-test screening of drivers would not have prevented these tuberculosis exposures.
Effect of Nursing in the Head Elevated Tilt Position (15°) on the Incidence of Bradycardic and Hypoxemic Episodes in Preterm Infants
Authors: Jenni Oskar G. , von Siebenthal Kurt , Wolf Martin , Keel Matthias , Duc Gabriel , Bucher Hans U.
Published: August 2004

Objective. We investigated whether nursing in the head elevated tilt position (HETP), compared with the horizontal position, has any effect on the incidence of bradycardic and hypoxemic episodes in preterm infants.

Methods. Twelve spontaneously breathing preterm infants with idiopathic recurrent apnea were studied in a randomized controlled crossover trial. Nine infants were treated with aminophylline. Each spent a total of 24 hours in the horizontal prone position and a total of 24 hours in HETP (prone, 15°). The position was changed in random order every 6 hours. Thoracic impedance, heart rate, and arterial oxygen saturation were recorded continuously. The frequency of isolated hypoxemia (arterial saturation <80%), of isolated bradycardia (heart rate <90 beats per minute), and of mixed events was analyzed and compared without knowledge of the allocated position.

Results. In total, there were significantly fewer bradycardic and/or hypoxemic episodes (28.2%) in HETP compared with the horizontal position (mean difference, 13.35 episodes/24 hours; 95% confidence interval [CI]: 5.9- 20.8). The decrease was largest for isolated hypoxemic episodes (48.5%; mean difference, 11.74 episodes/24 hours; 95% CI: 6.1–17.4). Isolated bradycardic episodes (mean difference, 2.27 episodes/24 hours; 95% CI: −0.78–5.31) and mixed events were not decreased significantly in HETP.

Conclusions. Nursing in a moderately tilted position (15°) reduces hypoxemic events in preterm infants. This intervention is easy to apply, quickly reversible, and can be combined with drugs such as aminophylline.
Pain and Pain Management in Newborn Infants: A Survey of Physicians and Nurses
Authors: Porter Fran Lang , Wolf Cynthia M. , Gold Jennifer , Lotsoff David , Miller J. Philip
Published: August 2004

Background. Despite an increased awareness among clinicians regarding pain and pain management for infants undergoing surgery, pain associated with procedures performed outside the operating room may not be adequately managed.

Purpose. To examine the beliefs and self-described behavior of physicians and nurses regarding the management of procedural pain in newborn infants.

Methods. A survey was distributed to 467 clinicians (nurses and physicians) working in 11 level II and 4 level III nurseries in a large metropolitan area. Respondents were asked to rate the painfulness of 12 common bedside nursery procedures and how often pharmacologic and nonpharmacologic (comfort) measures are currently used and should be used for those procedures. Demographic data were also collected.

Results. Surveys were completed by 374 clinicians (80% response rate). Physicians and nurses believe infants feel as much pain as adults and that 9 of the 12 listed procedures are moderately to very painful. Neither pharmacologic nor comfort measures are believed to be used frequently, even for the most painful procedures. Physicians and nurses believe both pharmacologic and comfort measures should be used more frequently, but nurses believe comfort measures should be used more frequently than do physicians. Beliefs about infant pain and procedural pain were related to pain management preferences. Physicians' but not nurses' ratings were associated with significant personal pain.

Conclusions. Despite their beliefs that infants experience significant procedure-related pain, clinicians believe pain management for infants remains below optimal levels. Barriers to more consistent and effective pain management need to be identified and surmounted.
Increased Behavior Problems Associated With Delayed School Entry and Delayed School Progress
Authors: Byrd Robert S. , Weitzman Michael , Auinger Peggy
Published: August 2004

Objective. To investigate whether students who are old-for-grade have higher rates of reported behavior problems and to investigate whether this association is independent of having been retained a grade in school.

Methods. Cross-sectional analyses of parental reports from the nationally representative sample of 9079 children ages 7 to 17 years who participated in the Child Health Supplement to the 1988 National Health Interview Survey. Students older than the modal age for their grade were considered old-for-grade, either due to delayed school entry (those without grade retention) or to delayed school progress (with history of grade retention). Behavior problems were defined as scores >90th percentile on a well-utilized, standardized Behavior Problem Index (BPI).

Results. Twenty-six percent of 7- to 17-year-old children in the United States are old-for-grade. Being old-for-grade is more common in males (31%), blacks (33%), Hispanics (32%), those living in single-parent households (31%) or poverty (43%), and those with mothers with low educational attainment (42%). Most children (84%) who repeated a grade are old-for-grade, but only 54% of old-for-grade students have been retained. For children who were old-for-grade, 19% of those grade-retained and 12% of those nonretained had extreme BPI scores, and for those not old-for-grade, 17% of grade-retained and 7% of nonretained children had extreme BPI scores. Although rates of extreme BPI scores were consistently lower for children who were neither old-for-grade nor grade-retained, and consistently higher for those with both, these rates increased with age for children who were old-for-grade without being retained. Controlling for multiple potential confounders with logistic regression, both old-for-grade status and grade retention are independently associated with increased rates of behavior problems. Separate logistic regression analyses for blacks and whites showed that these findings pertained only to white children.

Conclusions. Whereas grade retention is associated with increased rates of behavior problems in children and adolescents, simply being older than others in one's class, without having experienced grade retention, is also associated with increased rates of behavior problems, most noticeably among adolescents. These data suggest that there may be latent adverse behavioral outcomes that result from delaying children's school entry.
Endocrinologic Disorders and Optic Pathway Gliomas in Children With Neurofibromatosis Type 1
Authors: Cnossen Marjon H. , Stam Esther N. , Cooiman Linda C. M. G. , Simonsz Huibert J. , Stroink Hans , Oranje Arnold P. , Halley Dicky J. J. , de Goede-Bolder Arja , Niermeijer Martinus F. , Keizer-Schrama Sabine M. P. F. de Muinck
Published: August 2004

Objective. To establish the prevalence of endocrinologic disorders in children with neurofibromatosis type 1 (NF1) and the relationship between these disorders and cerebral abnormalities on magnetic resonance imaging.

Design. A prospective follow-up study.

Setting. A multidisciplinary neurofibromatosis clinic.

Patients. A total of 122 children diagnosed with NF1 according to diagnostic criteria set by the National Institutes of Health.

Results. Central precocious puberty (CPP) was diagnosed in 3 children and growth hormone deficiency (GHD) in 3 children. Optic pathway gliomas were observed in 15 children; in 9 of the 15 cases, the optic chiasm was involved. Of the 3 children with CPP, only 1 showed a chiasma glioma on magnetic resonance imaging. In 1 case with GHD, an optic chiasm glioma was detected on neuroimaging. Two of the 9 children with an optic chiasm glioma presented with CPP or GHD.

Conclusions. It has been suggested that CPP in children with NF1 is found exclusively in the presence of a chiasma glioma. We conclude that chiasma glioma may not be obligatory in children with NF1 and CPP or GHD. Moreover, we report a prevalence of GHD in children with NF1 of 2.5%, which has not been established earlier.
Bone Mineral Density in Prepubertal and in Adolescent and Young Adult Patients With the Salt-wasting Form of Congenital Adrenal Hyperplasia
Authors: Gussinyé Miquel , Carrascosa Antonio , Potau Neus , Enrubia Manuel , Vicens-Calvet Enric , Ibáñez Lourdes , Yeste Diego
Published: August 2004

Objective. To evaluate bone mineral density (BMD) in prepubertal and in adolescent and young adult patients with the salt-wasting form of congenital adrenal hyperplasia (CAH).

Design. A relationship between bone mineral content and risk for osteoporotic fractures has been observed in adulthood. Infancy, childhood, and adolescence are critical periods for skeletal mineralization; thus, chronic diseases may impair bone mass peaking, particularly if children and adolescents are overexposed to glucocorticoids, as may occur in patients with CAH.

Lumbar L2–L4 BMD values were measured by dual x-ray absorptiometry and compared with those of 471 age- and sex-matched controls.

Patients. Thirty-three patients with the salt-wasting form of CAH were studied. Sixteen (10 girls and 6 boys; age range, 1.5 to 8.3 years) were prepubertal and 17 (13 women and 4 men; age range, 17.1 to 28.2 years) were adolescent and young adults who had reached final height and had presented normal pubertal development and normal gonadal function thereafter. The average doses of hydrocortisone (mg/m2 body surface/day) received from diagnosis in the neonatal period to BMD evaluation were 21.2 ± 2.2 and 22.3 ± 2.6, respectively.

Results. Mean BMD Z score values were 0.16 ± 1.01 in prepubertal patients and 0.06 ± 1.02 in adolescent and young adult patients with no statistically significant differences with age- and sex-matched controls. Mean heightZ score values were −0.03 ± 1.13 in prepubertal patients and −1.13 ± 0.62 in adolescent and young adult patients with significant differences between the latter and their respective age- and sex-matched controls.

Conclusion. Long-term glucocorticoid therapy does not impair bone mass peaking in CAH patients with normal gonadal function, even though their adult height values are low.
A Residential Summer Camp for Children With Vertically Transmitted HIV/AIDS: A Six-Year Experience at The Hole In The Wall Gang Camp
Authors: Pearson Howard A. , Johnson Susanne , Simpson B. Joyce , Gallagher Maureen
Published: August 2004

Residential camping sessions for children with vertically transmitted human immunodeficiency virus/acquired immunodeficiency syndrome have been offered at The Hole In The Wall Gang Camp for the past six summers. More than 600 children 6 to 12 years of age have attended. Such sessions are expensive and require extensive planning. Medical and nursing needs have increased greatly over the 6-year period, reflecting advances in treatment and especially an escalation of prescribed medications. We have found it possible for these children to have a fun-filled camping experience and participate in a wide variety of activities.