bluuebunny/crossref_metadata_2025 huggingface dataset:
PUBLIC HEALTH, NURSING AND MEDICAL SOCIAL WORK
Authors: HARDY ALBERT V.
Published: December 2021

THERE are admitted limitations in our clinical examinations. The history may be biased. Significant departures from the normal may not be revealed by expert inspection, palpation and auscultation. Even x-ray is of help only when tissues of varying density are involved. Hence more and more we have turned to the laboratory for reliable data. It is to the great credit of the laboratories that in our teaching centers the results have had that degree of reliability which developed in our students a feeling of complete confidence in reported laboratory findings. It is not our intention to question whether this degree of confidence was warranted, but it is our purpose to make some observations on the reliability of laboratory examinations available to most of us in the practice of our profession. If laboratory findings are not as reliable as we expect them to be, can they be made so?

"Survey of the Accuracy of Chemical Analyses in Clinical Laboratories" by Belk and Sunderman has been quoted repeatedly. The Pennsylvania State Medical Society sponsored the study. The 59 laboratories which voluntarily participated were under the direction of pathologists and chiefly in hospitals. The quality of work of small laboratories operated by a technologist or performed by individual technicians in physicians' offices was not assessed. The findings, it is presumed, are the more favorable observations for laboratories of one state.

Samples for check-testing were submitted to the participating laboratories and results were reported and evaluated without identification of the laboratory concerned. To illustrate, a glucose solution with 60 mg. of glucose per 100 cc. was submitted, the result was considered satisfactory if readings were within the range of 50 to 70 mg. Of the 52 cxaminations reported, 33 were satisfactory.
SPECIAL REVIEWS
Authors: YANKAUER ALFRED
Published: December 2021

Present knowledge of child growth and development hinges around three general principles: the pattern-formation or stage, the individual uniqueness, and the interrelationship of all aspects of the growth process.

If we are to apply these principles to school children we need to recruit and select better personnel to work with them; we need to bring the benefits of this knowledge to such personnel in their training; we need to break down the tendency to compartmentalization of such personnel in their daily work with children.

If we are to apply these principles to a school program we need to knit all aspects of that program together more closely than ever before. This is particularly true of the relationship of school health services to the school curriculum.

Technics of measuring physical growth have been devised which are superior to former technics. Although they have a useful, if limited, role to play in the total school health program, their role in the screening and assessment aspects of the program remains in an experimental stage.
AMINO ACID METABOLISM IN PATIENTS WITH ACUTE LEUKEMIA
Authors: WAISMAN HARRY A. , PASTEL ROBERT A. , PONCHER HENRY G.
Published: December 2021

It has been shown that the free phenylalanine and tyrosine levels in plasma of patients with acute leukemia are significantly higher than in normal patients. Tyrosine and tyrosine metabolites in the urine are apparently normal, and the hyperpigmentation that has been observed in patients receiving folic acid antagonists cannot be directly related to tyrosine excretion in the urine or to the elevated melanin precursors in the blood. Isoleucine values were higher in the plasma of leukemia patients than in normal individuals. Several leukemia patients showed unusually elevated valine and methionine values. Creatine and creatinine excretion were normal in patients with acute leukemia.
SPECIAL REVIEWS
Authors: BARONDESS JEREMIAH A.
Published: December 2021

The studies which have led to the availability of gamma globulin for clinical use have been briefly reviewed, including those having to do with isolation, immunologic assay, purity, stability, safety and technic of administration.

Its use in a variety of virus infections has been described and reviewed, and the preliminary nature of many of these studies has been emphasized. It has been established that gamma globulin is an effective prophylactic agent not only in measles but in infectious (epidemic) hepatitis. Gamma globulin prepared from convalescent mumps serum is useful in reducing the incidence of complicating orchitis in mumps. There is evidence that it may be a valuable prophylactic agent against rubella. It gives promise of value as a prophylactic against poliomyelitis, although the definitive field trials are yet to be conducted. Its proper application in serum hepatitis and varicella is yet to be defined.

It would seem, in view of the uniformity of antibody titers, where it has been possible to measure these, and in view of the uniformity of protection from gamma globulin in a variety of conditions in which it has been tested, that the donors from whose plasma the material has been prepared have in general been immunized against these diseases, either by clinical or subclinical infection, and this reasoning may be extended to the general population from which these donors are drawn. Thus, aside from the practical clinical and epidemiologic applications which are appearing for gamma globulin, it shows promise of becoming an important tool in research in the basic biology of host-parasite relationships, including certain aspects of immunity as well as virus ecology.
Child Development Services in Medicaid Managed Care Organizations: What Does It Take?
Authors: Berry Carolyn , Butler Pamela , Perloff Linda , Budetti Peter
Published: December 2021

Objective.

We sought to understand why certain Medicaid managed care organizations (MMCOs) implemented child development services or programs and how they had done so. We also sought to identify barriers and facilitators to successful initiation and implementation of child development programs.

Methods.

We conducted 9 key informant interviews and 4 site visits, and performed qualitative analyses to identify major themes across responses.

Results.

We identified a small number of MMCOs with child development services. High-level support was crucial for program initiation; physician buy-in, staff support, and strong working relationships with outside health professionals or agencies were principal factors in successful program implementation.

Conclusions.

MMCOs that were committed to implementing child development services were successful in doing so, without external funding or regulatory mandate. The results provide valuable strategies for MMCOs interested in developing programs and for researchers and advocates interested in promoting child development services for low-income children.
Measuring the Process of Preventive Service Delivery in Primary Care Practices for Children
Authors: Gest Kathleen L. , Margolis Peter , Bordley W. Clayton , Stuart Jayne
Published: December 2021

Background.

Children may fall behind on preventive services because they do not receive needed services at the time of an office visit (a missed opportunity). However, methods are needed to measure problems in the care delivery process that lead to missed opportunities. We developed a method to examine the key steps in the preventive service delivery process and identify problems; we assessed the feasibility and validity of the method in primary care practices for children.

Methods.

Using 3 data collection methods, we measured key steps in the process of preventive service delivery in primary care offices: a chart audit was used to measure each child's preventive service status before and after an office visit, a brief parent exit interview was used to assess preventive service delivery not documented in the chart, and a staff checklist was used to assess the role of nursing and other office staff. The feasibility of using this combination of measures to identify problems in the care delivery process was evaluated in 3 representative primary care practices (2 pediatric, 1 family practice) among children 5 years and younger.

Results.

The measurement method was implemented in all 3 practices. The validity of the method was supported by its ability to detect differences among practices in the proportion of children eligible for immunizations and screening tests and in the proportion of children undergoing key steps in the process of preventive service delivery. The practice with the lowest proportion of children whose charts were screened for preventive services needs had the lowest performance of preventive services.

Conclusions.

It is possible to assess specific elements in the process of preventive service delivery in primary care practices. Use of this approach may help practices design and monitor interventions to improve the quality of preventive care delivery.
The Association Between Hands-On Instruction and Proper Child Safety Seat Installation
Authors: Lane Wendy G. , Liu Gilbert C. , Newlin Elizabeth
Published: December 2021

Objective.

To determine if hands-on instruction in child safety seat (CSS) installation decreases the number of errors in installation.

Design.

Cross-sectional study.

Setting.

Primary care offices, emergency department, CSS checkpoint.

Participants.

Parents of children <2 years old receiving medical care or attending a CSS check.

Main Outcome Measure.

Errors in CSS use.

Results.

Only 6.4% of parents had a correctly installed CSS. Hands-on instruction was associated with fewer errors in seat installation. Increased parent age, completion of college, and having private insurance were also associated with fewer errors in CSS placement. The majority of parents learned to install seats from reading the manual, from friends and relatives, and from figuring it out on their own.

Conclusions.

Errors in CSS installation are a significant problem. Hands-on instruction decreases the numbers of errors in CSS installation. However, few parents receive hands-on instruction from experts in CSS installation. Increases in correct CSS use could result from hands-on education by trained professionals.
Effect of a Reduced Postpartum Length of Stay Program on Primary Care Services Use by Mothers and Infants
Authors: Mandl Kenneth D. , Homer Charles J. , Harary Oren , Finkelstein Jonathan A.
Published: December 2021

Objective.

To determine the impact of reduced postpartum length of stay (LOS) on primary care services use.

Methods.

Design: Retrospective quasiexperimental study, comparing 3 periods before and 1 period after introducing an intervention and adjusting for time trends.Setting: A managed care plan.Intervention: A reduced obstetrical LOS program (ROLOS), offering enhanced education and services.Participants: mother-infant dyads, delivered during 4 time periods: February through May 1992, 1993, and 1994, before ROLOS, and 1995, while ROLOS was in effect.Independent Measures: Pre-ROLOS or the post-ROLOS year.Outcome Measures: Telephone calls, visits, and urgent care events during the first 3 weeks postpartum summed as total utilization events.

Results.

Before ROLOS, LOS decreased gradually (from 51.6 to 44.3 hours) and after, sharply to 36.5 hours. Although primary care use did not increase before ROLOS, utilization for dyads increased during ROLOS. Before ROLOS, there were between 2.37 and 2.72 utilization events per dyad; after, there were 4.60. Well-child visits increased slightly to .98 visits per dyad, but urgent visits did not.

Conclusion.

This program resulted in shortened stays and more primary care use. There was no increase in infant urgent primary care utilization. Early discharge programs that incorporate and reimburse for enhanced ambulatory services may be safe for infants; these findings should not be extrapolated to mandatory reduced LOS initiatives without enhancement of care.
Lumbar Puncture in Pediatric Bacterial Meningitis: Defining the Time Interval for Recovery of Cerebrospinal Fluid Pathogens After Parenteral Antibiotic Pretreatment
Authors: Kanegaye John T. , Soliemanzadeh Peyman , Bradley John S.
Published: December 2021

Objective.

Despite the lack of evidence defining a time interval during which cerebrospinal fluid (CSF) culture yield will not be affected by previous antibiotic therapy, recent publications cite a “minimum window” of 2 to 3 hours for recovery of bacterial pathogens after parenteral antibiotic administration. We conducted a retrospective review of children with bacterial meningitis to describe the rate at which parenteral antibiotic pretreatment sterilizes CSF cultures.

Methods.

The medical records of pediatric patients who were discharged from a tertiary children's hospital during a 5-year period with the final diagnosis of bacterial meningitis or suspected bacterial meningitis were reviewed. The decay in yield of CSF cultures over time was evaluated in patients with lumbar punctures (LP) delayed until after initiation of parenteral antibiotics and in patients with serial LPs before and after initiation of parenteral antibiotics.

Results.

The pathogens that infected the 128 study patients were Streptococcus pneumoniae (49),Neisseria meningitidis (37), group BStreptococcus (21), Haemophilus influenzae (8), other organisms (11), and undetermined (3). Thirty-nine patients (30%) had first LPs after initiation of parenteral antibiotics, and 55 (43%) had serial LPs before and after initiation of parenteral antibiotics. After ≥50 mg/kg of a third-generation cephalosporin, 3 of 9 LPs in meningococcal meningitis were sterile within 1 hour, occurring as early as 15 minutes, and all were sterile by 2 hours. With pneumococcal disease, the first negative CSF culture occurred at 4.3 hours, with 5 of 7 cultures negative from 4 to 10 hours after initiation of parenteral antibiotics. Reduced susceptibility to β-lactam antibiotics occurred in 11 of 46 pneumococcal isolates. Group B streptococcal cultures were positive through the first 8 hours after parenteral antibiotics. Blood cultures were positive in 74% of cases without pretreatment and in 57% to 68% of cases with negative CSF cultures.

Conclusions.

The temptation to initiate antimicrobial therapy may override the principle of obtaining adequate pretreatment culture material. The present study demonstrates that CSF sterilization may occur more rapidly after initiation of parenteral antibiotics than previously suggested, with complete sterilization of meningococcus within 2 hours and the beginning of sterilization of pneumococcus by 4 hours into therapy. Lack of adequate culture material may result in inability to tailor therapy to antimicrobial susceptibility or in unnecessarily prolonged treatment if the clinical presentation and laboratory data cannot exclude the possibility of bacterial meningitis.
Round Table Discussion
Authors: NETER ERWIN , LEPPER MARK H. , WEATHERMAN HAROLD , MCKEE WALTER C.
Published: December 2021

Chairman Neter: The advances made in the treatment of infectious diseases since 1935, and more particularly during the last decade, have been nothing short of miraculous. Surveying these accomplishments briefly, it is clear that adequate chemotherapeutic and antibiotic agents are available for many bacterial and rickettsial infections and even for a few diseases caused by the larger viruses, closely related to the rickettsiae. Furthermore, the medical profession has had available for many years drugs which have proved effective in maladies caused by some protozoa, such as malaria, and substantial further advances have been made in this field during the following World War II.

At the same time, we are all painfully aware that in the daily practice of pediatrics we are still lacking chemotherapeutic and antibiotic agents which are curative in diseases caused by the true viruses and, to a larger extent, in illnesses due to fungi. Also for certain bacterial infections, such as those caused by mycobacteria, Proteus, Pseudomonas and others, the ideal antibiotic will yet have to be discovered. Indubitably, the research that is going on throughout the civilized world in the search for newer and better antibiotics will, in due time, solve these all-important problems.

The field of antibiotic therapy and prophylaxis has expanded at such an extraordinary rate that it has not yet been possible in all instances to determine with certainty the relative efficacy of various antibiotics in all infections and the optimal dosage schedule for each. It is quite likely that all of us, for example, use more penicillin in some patients than is needed.
Evaluation and Development of Potentially Better Practices to Prevent Neonatal Nosocomial Bacteremia
Authors: Kilbride Howard W. , Powers Richard , Wirtschafter David D. , Sheehan Michael B. , Charsha Dianne S. , LaCorte Meena , Finer Neil , Goldmann Donald A.
Published: December 2021

Objective. Six neonatal intensive care units (NICUs) that are members of the Vermont Oxford National Evidence-Based Quality Improvement Collaborative for Neonatology collaborated to reduce infection rates. There were 7 centers in the original focus group, but 1 center left the collaborative after 1 year. The objective of this study was to develop strategies to decrease nosocomial infection rates in NICUs.

Methods. The process included a comprehensive literature review, internal practice analyses, benchmark studies, and development of practical experience through rapid-cycle changes, subsequent analysis, and feedback. This process led to 3 summary statements on potentially better practices in handwashing, approach to nosocomial sepsis evaluations, and central venous catheter management.

Results. These statements provide a basis for an evidence-based approach to lowering neonatal intensive care unit nosocomial infection rates.

Conclusions. The 2-year process also led to changes in the culture and habits of the institutions involved, which should in turn have long-term effects on other aspects of quality improvement.
Gastrointestinal Tract
Authors: Sreedharan Raman , Mehta Devendra I.
Published: December 2021

The developing gastrointestinal tract from conception to adolescence is in constant direct interaction with an increasingly complex environment. This sets up the potential for unrecognized acute as well as chronic disorders, some of which may be difficult to pinpoint in a developing infant and child, given the wide variations that exist. It is startling to note how early some environmental toxins can come into contact with the developing human, where vulnerability may be heightened and maturation of detoxifying pathways may be incomplete. Although the complex process of recognizing, detoxifying, and avoiding the toxic substance by the body has presumably evolved over a substantial period of time, in this rapidly changing world, the array of novel toxins that make their way into the gastrointestinal tract is increasing. There remain many gaps in understanding the effects of environmental toxins on all of the developmental stages from conception to adolescence. Although threshold levels have typically been derived from adult or animal data, factors such as size, relative differences in consumption in proportion to size especially in infancy, and variable physiologic maturation of metabolic pathways are not well understood. The vulnerability may be further accentuated by physical factors that alter with maturity, such as permeability and critical times during organogenesis or organ maturation. Also of concern is how little is known about low-dose, long-term exposure, as well as any interplay with common illnesses. This article focuses on environmental toxins that have been shown to have toxic effects on the gastrointestinal tract.
The Developing Kidney and Environmental Toxins
Authors: Solhaug Michael J. , Bolger Philip M. , Jose Pedro A.
Published: December 2021

The effects of environmental chemicals, drugs, and physical agents on the developing kidney are influenced by the state of renal development and maturation. The development of the kidney, the major excretory organ after birth, consists of 3 stages: the pronephros, or cervical kidney; mesonephros, or thoracic kidney; and metanephros, or abdominal kidney, the definitive kidney. In humans, nephrogenesis and organogenesis occur from the 6th to the 36th weeks of gestational age. After 36 weeks, nephrogenesis is complete and each kidney has a full complement of nephrons. The extent of chemical-induced renal toxicity is related, in part, to the efficiency in which the particular compound is transported by renal tubules. Because renal tubular transport capacities vary with maturation, the degree of nephrotoxicity may also vary with maturation. The signs and symptoms of nephrotoxicity can appear acutely or insidiously. Unexplained acute renal failure, chronic mild proteinuria, or even hypertension can be a manifestation of nephrotoxic agents. Species differences occur, thus the need for studies in humans.
Enhanced Sensitivity of the Postnatal Lung to Environmental Insults and Oxidant Stress
Authors: Finkelstein Jacob N. , Johnston Carl J.
Published: December 2021

Examination of the current state of health in the United States suggests that childhood lung diseases are increasing at an alarming rate. Looking more closely at the data, it can be seen that this increase is especially true for chronic respiratory diseases such as allergic asthma. This is a disease that is thought to have its roots in childhood insults. The demographics of the current wave of asthma and other chronic lung diseases reveal that the incidence is highest among children in polluted inner cities, where it seems to have reached epidemic proportions. This gives rise to a number of serious questions as to causality. Has the nature of the urban environment changed to such an extent as to lead to increased disease? Are current populations more sensitive to existing environmental insults? Is the increase real, or has our ability to detect it improved? This article addresses the possibility that factors intrinsic to the lung and its development have combined with specific environmental risk factors to have an adverse impact on children’s health.
Risk Assessment and Child Health
Authors: Samet Jonathan M.
Published: December 2021

Risk assessment, an approach for organizing information about hazards to health, safety, and the environment, provides a framework for gauging the threat to child health from environmental pollutants. A qualitative risk assessment has 4 components: hazard identification, dose-response assessment, exposure assessment, and risk characterization. In a risk assessment, consideration can be given to a population group that potentially has increased susceptibility, whether arising from having a high level of exposure or from increased susceptibility to the agent of concern on a biological basis. Children have been proposed as being at increased risk from some environmental agents, and there has long been concern and debate that the current approach of determining acceptable exposure levels or intake for a person may not yield safe intake limits for infants and children, who may be placed at greater risk than adults because of exposure patterns and inherent susceptibility. The persistence of debate on this critical public health issue reflects, in part, the difficulty of developing sufficiently sensitive and validated animal bioassays for critical outcomes. Epidemiologic studies can play only a limited role, given the complexity of establishing cohorts and tracking exposures from conception forward to assess risks across the lifespan. Meeting society’s call for healthy environments for children poses an extraordinary challenge to researchers and to the policy makers who seek to develop evidence-based policies to protect children.
HYPERTENSIVE PHASE OF ACUTE NEPHRITIS
Authors: ROYCE STEPHEN W.
Published: December 2021

The hypertensive phase of acute nephritis remains crucial and difficult to control. In a small series of cases prompt remission of hypertension and accompanying complications occurred following the use of a derivative of veratrum viride.
SERUM MUCOPROTEINS IN PATIENTS WITH RHEUMATIC FEVER
Authors: KELLEY VINCENT C. , ADAMS FORREST H. , GOOD ROBERT A.
Published: December 2021

Serum mucoprotein concentrations during various stages of rheumatic fever are compared to those of normal children and children suffering from a variety of diseases.

In untreated rheumatic fever as in rheumatic fever treated with bed rest and salicylates the concentration of mucoproteins in the serum appears to be useful index of rheumatic activity.

Treatment of rheumatic fever with ACTH or cortisone causes deviation of the elevated serum mucoprotein concentration toward normal but hormonal treatment has less effect on this "acute phase reactant" than on other objective indices of rheumatic activity.

A tendency of the mucoprotein concentration to "plateau" at elevated levels in spite of hormone treatment is described. The possibility that maintenance of elevated mucoprotein levels during hormone therapy indicates persisting disease activity is suggested.

The tendency to develop recurrent rheumatic symptomatology following cessation of hormone treatment is correlated with concentration of mucoproteins in the serum and with the total duration of treatment.
PUBLIC HEALTH, NURSING AND MEDICAL SOCIAL WORK
Authors: CUNNICK DOROTHY GILDEA , FINBERG LAURENCE
Published: December 2021

A situation in which responsibility for care of foster children fell to a teaching pediatric service, provided an opportunity for extending a pediatric house officer's activities into a sociologic sphere. Every house officer has had some contact with social problems discovered as part of outpatient care, but in the instance to be described these problems were so concentrated that active participation by the pediatric house staff seemed a logical and necessary step.

The Baltimore City Hospitals' Pediatric Division supplies the medical care for the wards of the Children's Division of the Department of Public Welfare. This agency supervises about 2,300 children in foster homes in the city of Baltimore. As these children were brought to the outpatient department for one or another reason, we were constantly confronted with the special Problem of the adolescent girl in a foster home.

The manifest special problems of the age group were concerned with sexual relations-Promiscuity, prostitution, illegitimate pregnancy amid its consequences, and venereal disease. Particularly trying to the clinic physicians in their attempts to develop a satisfactory physician-patient relationship with these girls were their attitudes of resentment, their lack of even minimal information on matters of basic hygiene, and their unawareness of "accepted" social conduct.
STUDIES OF THE MECHANICAL FRAGILITY OF ERYTHROCYTES
Authors: HSIA DAVID YI-YUNG , GOLDBLOOM RICHARD B. , GELLIS SYDNEY S.
Published: December 2021

The mechanical fragility of the erythrocytes of newborn infants is markedly elevated and falls to normal levels by the fifth and sixth day. There appears to be an inverse correlation between the rate of fall of mechanical fragility in the neonatal period and the rise of serum bilirubin. There appears to be a direct correlation between the height of mechanical fragility of erythrocytes on the first day and the subsequent degree of hyperbilirubinemia. The relation of these observations to physiologic jaundice are discussed.
ANORECTAL RINGS IN INFANCY: INCIDENCE AND SIGNIFICANCE
Authors: HARRIS LLOYD E. , CORBIN H. PENUEL F. , HILL JOHN R.
Published: December 2021

Anorectal rings were found in 13.8% of 1,716 consecutive newborn infants. The anorectal ring was detected in four times as many females as males.

Anorectal rings of the grades discovered in this study dilated spontaneously and did not require treatment.

The incidence of constipation, colic, blood in the stool, excessive straining, distention, tear of the anal skin, and crying with defecation was the same in a group of 168 infants with anorectal rings as it was in a group of 160 infants in whom the anorectal ring was absent.

A thick, fibrous anorectal ring which does not dilate spontaneously may cause obstructive symptoms and require treatment. This type of anorectal ring did not occur in this group of 1,716 infants.
INDUCED RENAL HYPERCHLORAEMIC ACIDOSIS
Authors: ISRAELS S. , DELORY G. E. , GOURLEY BETH
Published: December 2021

An infant without previous renal disease was given a carbonic anhydrase inhibitor (No. 6063). Following administration of the drug the serum alkali reserve fell, serum chloride rose and the urine became less acid. The "total carbon dioxide" excreted in the urine was also increased following administration of the inhibitor.
STUDIES OF SERUM ELECTROLYTE CHANGES DURING EXCHANGE TRANSFUSION
Authors: MILLER GERALD , MCCOORD AUGUSTA B. , JOOS HOWARD A. , CLAUSEN SAMUEL W.
Published: December 2021

Alterations in concentrations of serum potassium are reported in infants studied during exchange transfusion therapy for erythroblastosis. The elevated plasma potassium content of citrated whole blood following prolonged storage may produce hyperkaliemia in some infants. The authors have suggested that hypocalcemia and hyperkaliemia may coexist in some of these babies during exchange transfusion. Certain implications regarding the cumulative effects of these two disturbances are discussed in relation to exchange transfusion.
AN EPIDEMIC OF DIARRHEA OF THE NEWBORN CAUSED BY ESCHERICHIA COLI O-111, B4
Authors: STULBERG CYRIL S. , ZUELZER WOLF W. , NOLKE ANTHONY C.
Published: December 2021

An outbreak of diarrhea of the newborn in a premature nursery has been described. The results of bacteriologic, epidemiologic, and therapeutic studies identified the etiologic agent as a specific type of coliform organism, Escherichia coli O-111, B4.

This organism was isolated in virtually pure culture from the stools of 24 premature infants who developed diarrhea. It was not found in premature infants who were effectively isolated and who remained clinically well. E. coli O-111, B4 was not present in the stools of patients before their illness started but was isolated, again in practically pure culture, almost simultaneously with the onset of symptoms.

Neomycin proved to be an effective chemotherapeutic agent, both in eliminating the organism from the stools and causing the cessation of symptoms within a short time of each other.

Three patients died. Their case histories and post-mortem findings with relation to the pathogenesis of the disease are discussed.
AMINO ACIDURIA AND ASCORBIC ACID DEFICIENCY
Authors: JONXIS J. H. P. , HUISMAN T. H. J.
Published: December 2021

In two cases of infantile scurvy an increased output of amino acids was found which disappeared during three or more weeks of ascorbic acid administration. The excretion of threonine, serine, glycine, tyrosine, histidine, lysine and β-amino-isobutyric acid was increased, that of the other amino acids being normal. Plasma ultrafiltrates from two scorbutic infants were found to contain amino acids in similar concentrations to those of two control infants. The amino aciduria of scurvy is thus apparently of renal origin.
REVIEW ARTICLE
Authors: MAY CHARLES D.
Published: December 2021

WITHIN the past year a dramatic outbreak of a singular type of convulsive seizures in babies has provided convincing evidence of an essential role for Vitamin B6 in human nutrition under natural circumstances. This is a general review of the circumstances surrounding this outbreak and of the present state of our knowledge of vitamin B6.

But it is also important that this episode be considered as a reminder of the complex interrelationships which permeate studies of nutritional factors and as a warning against hasty conclusions. It also serves as an illustration of the hazard in premature or uncontrolled application to human nutrition of isolated fragments of knowledge concerning nutritional factors.

The existence of Vitamin B6 was discovered in 1934 by experiments with rats. Symptoms of deficiency of this vitamin were soon described in several species of animals but not in man. Within a few years the chemistry of the vitamin was determined and the synthesis achieved. Considerable information as to the metabolic reactions affected by a deficiency of Vitamin B6 was rapidly accumulated. Only recently, 16 years after the discovery of Vitamin B6, the Council on Pharmacy and Chemistry of the American Medical Association reviewing the status of our knowledge of the role of Vitamin B6 in human nutrition reached only a cautious acceptance of an essential dietary requirement for Vitamin B6 in the human.

The original observations which called attention to the problem of unusual convulsions in infants and pointed the way to its solution were made by a doctor in practice, just as were similar observations which led a few years ago to an appreciation of the circumstances producing a deficiency of folic acid in infancy.
OXYGEN ADMINISTRATION AND RETROLENTAL FIBROPLASIA
Authors: GORDON HARRY H.
Published: December 2021

THE ORIGINAL description by the Owens of the clinical evolution of the lesions of retrolental fibroplasia stimulated a wide search for a postnatal cause. Conclusive evidence that the administration of oxygen is the major cause has been reviewed. This editorial comment is prompted by the confusion about translating the evidence into Practice.

The data proving the importance of administration of oxygen consist of both clinical and laboratory observations. In 1952 Patz, Hoeck and de la Cruz reported a series of careful, controlled clinical observations from the District of Columbia General Hospital. Alternate infants weighing less than 3.5 pounds at birth were assigned to high or low oxygen and followed with careful ophthalmoscopic examinations for at least 6 months. Oxygen concentrations were measured 3 times daily and flows adjusted to maintain the desired concentrations. In a group of 28 infants kept in 65 to 70% oxygen for 4 to 7 weeks, seven or 25% showed permanent residua which included detachment of the retina. In 37 infants who received minimal oxygen, never more than 40%, from 1 day to 2 weeks, none developed residual changes. During a second year of alternation, these results were confirmed: of a total of 60 infants in high oxygen, 12 showed residua as compared with 1 in low oxygen. These clinical studies have been supported by independent uncontrolled studies from Australia, England, Switzerland, Denver, and Montreal, a more recent controlled study from New York, and an epidemiologic survey in Maryland; they bear out the original suggestion of Kinsey and Zacharias, that increased use of oxygen was one of the changes in care of premature infants which might be responsible for retrolental fibroplasia.
PROLONGED INTERMITTENT ACTH AND CORTISONE THERAPY IN THE NEPHROTIC SYNDROME; IMMUNOLOGIC BASIS AND RESULTS
Authors: Lange Kurt , Slobody Lawrence , Strang Ruth
Published: December 2021

1) Serum complement levels were always low in 40 cases with acute and subacute glomerulonephritis.

2) Serum complement levels were low in 27 of 29 cases with the nephrotic syndrome whether or not underlying glomerulonephritis could be demonstrated.

3) The low complement levels were not due to loss of complement into the urine, lack of formation or anticomplementary factors.

4) Spontaneous remissions of the nephrotic syndrome were preceded in 11 of 13 instances by high fever. Depression of the eosinophil count (4 patients) and a rise in urinary 17-ketosteroids (1 patient) were observed.

5) Complement rose prior to the diuresis in spontaneous remissions, and fell prior to relapses.

6) Rise in serum complement and diuresis occurred independent of changes in plasma protein levels and changes in plasma oncotic pressure.

7) In the nephrotic syndrome large doses of ACTH and oral cortisone led to a rise in complement levels followed by diuresis. Relapses were preceded by a fall in complement.

8) ACTH given for 3 to 8 weeks on 3 successive days of each week after an initial 7 to 10 day course of ACTH was accompanied by long-lasting remissions in 3 out of 6 patients.

9) Oral cortisone given in high doses in a similar schedule after an initial 7 to 10 day course of ACTH was accompanied by long remissions in 16 out of 18 patients when given for 6 to 30 courses.

10) Cortisone maintenance therapy led to a rapid return to normal in the levels of plasma protein and cholesterol and a reduction of proteinuria.

11) Cortisone maintenance therapy did not produce diuresis in 4 patients but prevented relapses in a high percentage of patients.

12) There was no fatality in 29 patients with the nephrotic syndrome observed for from 3 to 40 months during or after maintenance therapy.
REPORT OF THE LIAISON REPRESENTATIVE TO THE CHILDREN'S BUREAU
Authors: Webb Clarence H.
Published: December 2021

DURING the past year the Children's Bureau has given special attention outside of its regular activities, to three problems which should be of some interest to Academy members because of their nationwide significance and almost universal applicability. These activities have been directed at mentally retarded children, children of migrant families, and juvenile delinquency.

1. Mentally Retarded Children. The past few years have seen an upsurge in attention on to and planning for the medical care and educational needs of "exceptional" children, and particularly the mentally retarded child, since this is by fart the largest segment. Part of the Children's Bureau's special work in this field has been in fostering studies of this problem as well as in giving assistance to state groups in meeting their particular problems. It is hoped that during the coming year the Bureau can give assistance and advice where it is desired, to Academy members in states where the problem of caring for the mentally retarded is urgent. State Chairmen can call to the attention of Academy members the opportunities which pediatricians have to give guidance and assistance to parent groups and other bay organizations which are attempting to meet the needs of retarded children and other exceptional children.

2. Children of Migrant Families. The Children's Bureau has engaged in a study of migrant families along the Eastern seaboard. The Bureau hopes to extend these studies to the two larger migrant streams, one which passes through Texas to Colorado and the Midwest and the other along the Pacific Coast. Difficult problems are offered which involve the coordination of medical, educational, and welfare services through the various agencies concerned. The rapid transit of these people from state to state creates special problems.
PROGEROID SYNDROME
Authors: Grossman Herbert J. , Pruzansky Samuel , Rosenthal Ira M.
Published: December 2021

The case of a severely dwarfed microcephalic child is reported whose growth disturbance probably began in utero. Serial cephalometric studies were done and are reported. No explanation could be found for her condition, and no similar case can be found in the literature. The superficial resemblance of the child to an aged person warrants the classification of her condition with a miscellaneous group of cases under the term "progeroid syndrome," but it must be noted that her appearance was the result of a severe growth disturbance rather than of true premature aging.
REVIEW ARTICLE
Authors: Najjar Victor A.
Published: December 2021

THE ASTONISHING success of chemotherapeutic agents in the treatment of infectious diseases has rendered the management of such cases relatively simple and rewarding thereby shifting emphasis to less common clinical problems in pediatrics. A decade ago, metabolic diseases constituted a mere fraction of the clinical problems encountered; but now make up a large segment of those cases that call for unusual skill and wide knowledge of disease. A clear understanding of metabolic processes has therefore become necessary for the study and management of such cases.

The main factors concerned with the normal function of an organ are its constituent enzymes and the forces that influence enzyme function. The latter are chiefly hormonal and nutritional influences. In recent years, there has been a very rapid advance in our knowledge of the enzyme systems involved in carbohydrate and fat metabolism and the factors that affect the function of those systems.

These advances have placed before the student of metabolism a pattern of stepwise processes that determine the direction and efficiency of metabolism in synthesis or degredation. These orderly processes make it possible to predict more or less accurately, the metabolic picture that may result from a defect in any one particular step. It was with this in mind that a few metabolic diseases were studied and precise biochemical lesions discovered. In some instances these defects were enzymatic and in others essentionally hormonal. This is truly a reversal of the course of events more commonly encountered, because it is often the metabolic disease that furnishes the stimulus for the advances in the physiology of metabolism.

Knowledge for knowledge's sake has characterized this era of rapid physiological advances. The more advanced and orderly this process is, the easier it shall be for the clinician to understand and treat disease.
EPIDEMIC DIARRHEA AMONG INFANTS ASSOCIATED WITH THE ISOLATION OF A NEW SEROTYPE OF ESCHERICHIA COLI: E. COLI 0127:B8
Authors: Cooper Merlin L. , Walters Edward W. , Keller Helen M. , Sutherland James M. , Wiseman Hollis J.
Published: December 2021

During an outbreak of epidemic diarrhea a new serotype of Escherichia coli: E. coli 0127:B8, was isolated from 44 of 145 infants and from 1 nurse among 82 adult personnel in attendance. Among the 44 infants whose rectal swab cultures were positive, 20 were in the first month of life, 16 were 2 to 6 months of age, and 6 were 7 to 12 months of age, a total of 42 being in the first year of life.

Severe epidemic diarrhea associated with the presence of E. coli 0127:B8 was characterized by the sudden development of extreme abdominal distention among some of the infants; explosive onset of diarrhea and the presence of a pungent, musty, objectionable odor not noticed around other patients with diarrhea.

E. coli 0127: B8 was isolated more frequently while the patients were having diarrhea.

Neomycin® was used orally for the specific treatment of patients with diarrhea. The early dosage was small due to our caution in using a new antibiotic. Over the 4 months period of this study the dosage was gradually increased. The average dose was 40 mg./kg./day for the patients with positive cultures and 46 mg./kg./day for those with negative cultures.

Of 22 patients with positive cultures, 12 who were treated with Neomycin® alone or in addition to other antibiotics continued to show the presence of E. coli 0127:B8 after Neomycin® therapy had been terminated; however, only 2 of these patients had recurrence of diarrhea, both having had negative cultures while receiving Neomycin®.

The administration of Neomycin® to every infant on the 2 wards, regardless of clinical condition, was followed by a decreasing incidence of diarrhea and decreasing detection of E. coli 0127:B8. The dose of Neomycin® was 40 to 50 mg./kg./day. It is our feeling that Neomycin® administered orally was of definite clinical value therapeutically and prophylactically but in the dosage used was inadequate bacteriologically.

Four deaths occurred among the 44 infants whose rectal swab cultures were positive for E. coli 0127:B8 and necropsy studies were made on each. A hemorrhagic enteritis was present in 3 infants and in the fourth infant the cause of death was a congenital heart condition. Death of 1 patient with negative rectal swab cultures may very likely be attributed to severe diarrhea.

Sera from patients and personnel failed to show the presence of agglutinins for E. coli 0127:B8.

in vitro sensitivity tests showed that the order of decreasing bactericidal effectiveness of 5 antibiotics for E. coli 027:B8 was polymyxin, Neomycin®, chloramphenicol, Achromycin®, and Terramycin®. All strains were resistant to dihydrostreptomycin and sodium sulfadiazine. Only the last strains isolated from 2 patients showed increased resistance to Neomycin®, four-and sixteenfold when compared with the first strains isolated from the same patients.
THE NEWBORN PATIENT
Authors: Smith Clement A.
Published: December 2021

TO BE ENTRUSTED with the honor delivering a lecture named for Doctor Clifford Sweet is to be handed no easy assignment. The lecturer's basic problem is increased by the fact that the assignment comes from Doctor Sweet's local professional colleagues. These men, who have worked side by side with him as the Children's Hospital of the East Bay has extended its good influences—and his—not only know Doctor Sweet much better than does your lecturer, but must also know how great is their affection for him. Naturally, they hope I will tell Doctor Sweet some of these things for them. Like Myles Standish long ago on the shores of another and more eastern bay, they expected their Twentieth Century John Alden to put into graceful words those deep feelings they find themselves unable to express.

I am quite unable to carry out such a commission. John Alden, with a little gentle prodding, is said to have decided to speak for himself. I shall speak for myself, too, and for my own colleagues who respect Doctor Sweet as a doctor first, as a pediatrician second, and as a specialized pediatrician third. We say this with admiration in an age when many pediatricians have become so narrowly specialized that their functions as doctors have become almost vestigial. It has been a great pleasure to spend these few days in the company of one so 50 wise in so many aspects of medicine.

I stand before you self-indicted as one of those narrow specialists who has allowed himself to be pushed into increasingly restricted medical territory.
SPLENECTOMY IN MEDITERRANEAN ANEMIA
Authors: Clement David H. , Taffel Max
Published: December 2021

Although the primary defect in Mediterranean anemia is an inability to synthesize adequate amounts of hemoglobin, a hemolytic component eventually supervenes, associated with splenomegaly which in turn is augmented by the necessary transfusions.

When the disease bias been evident for some time, the spleen is greatly enlarged and the transfusion requirement is big, splenectomy may be effective in greatly reducing the frequency of transfusions to 25 to 50 per cent of the pre-splenectomy need.

Secondary benefits following splenectomy have included improvement in disposition, appetite and activity and lessened fatiguability. Overloading with iron is diminished, a feature theoretically diesirable in view of the ever-present hemochromatosis. Psychic trauma to the child and expenditure of the physician's time in transfusions are proportionately decreased.

Failure to benefit from splenectomy may be expected if the organ is removed early in the course of the disease before it has greatly enlarged and the transfusion need is great. It is also possible that the operation will accomplish little in the terminal phase of the disease when the liver is huge and the marrow over-extended.

Optimum time for splenectomy and the best criteria for the selection of patients remain to be evolved but we are convinced that removal of the spleen under appropriate circumstances is of substantial benefit to these patients. The procedure has been well tolerated in our small series. Complications have not been encountered, though thrombosis remains a threat in view of the high platelet counts encountered postoperatively. Early ambulation and even anticoagulant therapy (not yet employed by us) may be useful. Platelet counts should be followed closely.
NEONATAL HYPOGLYCEMIA
Authors: Schwartz Oscar , Goldner Martin G. , Rosenblum Jacob , Avin Joseph
Published: December 2021

A case of neonatal hypoglycemia of 23½ months' duration associated with recurrent convulsions has been presented.

The case best fits the classification of "idiopathic spontaneous hypoglycemia in infants."

Dietary management was partially successful for a period of 2½ months.

The therapeutic effects of administration of glucagon, cortisone and ACTH were studied. Only the administration of cortisone and ACTH permitted control of the hypoglycemic state.