bluuebunny/crossref_metadata_2025 huggingface dataset:
Effect of Gender, Race, and Parental Education on Immunogenicity and Reported Reactogenicity of Acellular and Whole-Cell Pertussis Vaccines
Authors: Christy Cynthia , Pichichero Michael E. , Reed George F. , Decker Michael D. , Anderson Edwin L. , Rennels Margaret B. , Englund Janet A. , Edwards Kathryn M. , Steinhoff Mark C.
Published: December 2021

Objective. To determine whether gender, race (black or white), or level of parental education influenced serologic responses or reporting of clinical reactions after immunization with acellular (DTaP) or whole-cell (DTP) pertussis vaccine with diphtheria and tetanus toxoids combined.

Methods. Healthy infants were prospectively randomized to receive one of 13 DTaP, Lederle DTP, or another DTP. Parents recorded the occurrence of adverse reactions for 2 weeks after each inoculation. Sera obtained before the first immunization and 1 month after the third immunization were analyzed for antibody to pertussis toxin, filamentous hemagglutinin, fimbriae, and pertactin (PRN). Chinese hamster ovary cell pertussis toxin neutralization assays were performed, and levels of agglutinating antibodies determined.

Results. Prevaccination antibody levels did not differ by race, gender, or parental education. Postimmunization geometric mean titers (GMTs) were strongly and consistently associated with race. For both DTaP and DTP and for every included antigen, postimmunization GMTs were about twice as high for black as for white infants. Among DTaP recipients, these differences were significant for pertussis toxin, Chinese hamster ovary cell pertussis toxin neutralization assay, filamentous hemagglutinin, and agglutinins; among the much smaller sample of WCL recipients, the differences achieved or approached statistical significance for agglutinins, PRN, and fimbriae. These findings were confirmed by regression analyses that controlled for gender, parental education, study site, and preimmunization antibody level. Reported reactions were not correlated with parental education level and showed no material correlation with gender. Black infants were reported to have had more pain than white infants after receiving WCL and DTaP and were reported to be more fussy after receiving WCL.

Conclusions. The consistently higher postimmunization GMTs among black infants seems to be a real finding for which we have no explanation; the infants did not significantly differ by race in vaccine assignment, preimunization antibody levels, age at immunization, or interval from immunization to phlebotomy. These observations should be confirmed and further evaluated in future pertussis vaccine trials. Reported differences by race in pain and fussiness after receiving WCL might reflect chance, differences by race in the occurrence of reactions, or differences by race in the reporting of reactions.
The Reverse Cumulative Distribution Plot: A Graphic Method for Exploratory Analysis of Antibody Data
Authors: Reed George F. , Meade Bruce D. , Steinhoff Mark C.
Published: December 2021

Serologic data often have a wide range and commonly do not approximate a normal distribution. Means, medians, SDs, or other conventional numerical summaries of antibody data may not adequately or fully describe these complex data. The reverse cumulative distribution plot is a graphic tool that completely displays all the data, allows a rapid visual assessment of important details of the distribution, and simplifies comparison of distributions.
Corporal Punishment
Authors: Trumbull Den A. , Ravenel DuBose , Larson David
Published: December 2021

The supplement to Pediatrics entitled "The Role of the Pediatrician in Violence Prevention" is timely, given the increasingly serious violence problem in the United States.1 Many of the supplement's recommendations are well-conceived and developed. However, the recommendation to "work toward the ultimate goal of ending corporal punishment in homes" (page 580)2 is unwarranted and counterproductive.

Before one advises against a practice approved by 88% of American parents3 and supported by 67% of primary care physicians,4 there should be sufficient scientific evidence to support the proposed change in social policy.
Dietary Fiber in Weaning Foods of Young Children
Authors: Agostoni Carlo , Riva Enrica , Giovannini Marcello
Published: December 2021

Objective. An evaluation of the opportunity to introduce fiber in the diet of weaning infants.

Methods. A descriptive review of the literature to assess the role of fiber in the following dietary interventions: (1) definition of the nutrient amounts that meet the weaning infant's physiologic needs; (2) modulation of digestive and absorption processes; and (3) improving the nutritional balance between the 6th and the 12th months of life and setting habitual dietary patterns for subsequent years.

Findings. Whole cereals, nonstarchy vegetables, fruits, and legumes lower the caloric and proteic density of meals, modulate nutrient and antigen absorption, and provide bulk material. They supply proteins of low biological value, minimal amounts of lipids (mostly essential polyunsaturated), complex carbohydrates, and soluble fiber, which are fermented into short-chain fatty acids by the colonic flora, and insoluble fiber that modulates intestinal function. Minerals, trace elements, and vitamins add to the value of fiber-containing foods in the diet. Recent nutritional surveys indicate that the diets of 12-month-old infants tend to include too much animal proteins and to be too protein-dense, which could be corrected with an increase of fiber-containing foods.

Conclusions. Fiber-containing foods share unique characteristics with nutritional and metabolic implications for the weaning infant. Whole cereals, green vegetables, and legumes should be routinely introduced during the weaning process to achieve a better nutritional balance and to accustom children to diets with fiber content. The daily intake of fiber should be gradually increased to 5 g/d during the second semester of life.
Beliefs and Practices Regarding Childhood Vaccination Among Urban Pediatric Providers in New Jersey
Authors: Askew George L. , Finelli Lyn , Lutz James , DeGraaf Janet , Siegel Bruce , Spitalny Kenneth
Published: December 2021

Background. In 1991, the fourth largest measles outbreak in the nation (824 cases) occurred in the Jersey City, New Jersey area. Data from a subsequent intervention trial in Jersey City demonstrated that vaccinations were more likely to be delayed for children who had received care from private rather than public clinic providers. In addition, failure to administer multiple indicated vaccines at a single visit was associated with vaccination delay, and reluctance to administer multiple vaccines was more common among private providers. These findings prompted an investigation of vaccination beliefs and practices among urban pediatric providers.

Methods. A telephone survey of vaccination beliefs and practices was administered to all pediatric providers in both private and public clinics in the Paterson and Jersey City areas.

Results. Private providers were less likely than public clinic providers to consider vaccinating children during emergency room visits (relative risk [RR] = 2.2; 95% confidence interval [CI] = 1.2-4.2) or hospital admissions (RR = 13.2; 95% CI = 1.9-92.7) and less likely to believe that all recommended vaccine doses should be administered simultaneously (RR = infinite; lower 95% confidence limit = 3.0). Private providers were less likely to consider administering live-virus vaccines to children with minor acute illnesses and low-grade fever (RR = 2.2; 95% CI = 1.2-3.8) or killed-virus vaccines to children with minor acute illnesses without fever (RR = 3.4; 95% CI = 1.4-8.5) or with low-grade fever (RR = 2.2;95% CI = 1.2-3.9). Private providers were more likely to believe that multiple injections should be avoided because of potential psychological and physical trauma to the child (RR = 4.0; 95% CI = 1.3-12.3).

Conclusions. Adherence to Standards for Pediatric Immunization Practices by pediatric providers could improve vaccine coverage rates among urban children.
Elevated Serum Lactate Correlates With Intracranial Hemorrhage in Neonates Treated With Extracorporeal Life Support
Authors: Grayck Eva Nozik , Meliones Jon N. , Kern Frank H. , Hansell Doug R. , Ungerleider Ross M. , Greeley William J.
Published: December 2021

Objectives. To correlate the initial and maximal lactate levels with the occurrence of intracranial hemorrhage (ICH) and survival in patients treated with extracorporeal life support (ECLS).

Design. Retrospective chart review.

Setting. Pediatric intensive care unit.

Patients. Eighty-two neonatal patients placed on ECLS for respiratory failure due to sepsis, meconium aspiration, or persistent pulmonary hypertension of the newborn.

Measurements. The initial lactate level measured within 6 hours of initiating ECLS and the maximal lactate level measured throughout the ECLS course were collected. Lactate levels were described as mean lactate ± SE (mM). Head ultrasound reports and survival were reviewed. Platelet counts and activated clotting times (ACTs) were examined.

Results. The mean initial and maximal lactate levels were higher in ECLS patients who developed ICH (initial: 10 ± 1.7 mM vs 6.4 ± 0.8 mM, p = .05 and maximal: 12.4 ± 2.5 mM vs 7.9 ± 0.8 mM, p = .04). Initial and maximal lactate levels were also elevated in nonsurvivors (initial: 11.7 ± 3 mM vs 6.4 ± 0.7 mM, p = .01 and maximal: 14.8 ± 3.3 mM vs 7.8 ± 0.8 mM, P < .01). Platelet counts and ACT did not differ in patients with and without ICH.

Conclusions. Lactate is a useful marker for the development of ICH in ECLS patients. In addition, elevated lactates during ECLS identify a subgroup of patients with poor outcome. Prospective studies are needed to determine whether the incorporation of this information into pre-ECLS and ECLS management will decrease the occurrence of ICH and improve survival.
WHAT EXACTLY MAKES A HOSPITAL THE ‘BEST’?
Authors: L. J. F.
Published: December 2021

Make sure your fax machine is turned on and full of paper when you leave your office Wednesday night, read an advisory to more than 125 major medical centers...

... Fax machines around the country whirred into action as U.S. News and World Report notified the winners of its annual rankings of the best hospitals. That same morning, about 100 reporters and editors received bulging press packets touting the winners.

U.S. News's 6-year-old Consumer guide to hospitals has become the hottest marketing tool in the health-care industry, a public-relations gold mine for the winning medical centers. The magazine wins, too, because the "Best Hospitals" issue generally sells slightly better than the average U.S. News and leads to a booming business selling reprints to winning hospitals.

But the rankings—which this year include 128 hospitals in 16 specialties—are also coming under fire. Officials at two major hospitals, University Hospitals of Cleveland and Hospital of the University of Pennsylvania, say the list is little more than a popularity contest because the methodology is flawed.
Early Discharge Alert
Authors: Lawrence Ruth A.
Published: December 2021

Early discharge from the hospital after birth has transformed a special rite-de-passage into a crisis for the family. One of the victims of this crisis may be an infant who is breastfeeding. When the process of breastfeeding is not going well, a common response is often to abandon breastfeeding and turn to artifical feeding. Breastfeeding, however, is the ideal method of feeding for the human infant. Human milk is species-specific, ideal for brain growth, physical nourishment, infection protection, immunologic protection, allergy avoidance, and optimal mother-infant interaction. Breastfeeding may be difficult for some mothers because we live in a bottle-feeding culture where the symbol for infancy is a bottle.
New Developments With Pertussis Vaccines
Authors: Halsey Neal A. , Peter Georges
Published: December 2021

Extensive efforts on the part of the National Institutes of Health (NIH), vaccine manufacturers, and other investigators in the United States and Europe have generated important new information regarding the efficacy of several acellular and whole-cell pertussis vaccines administered to infants. Multiple acellular pertussis vaccines combined with tetanus, and diphtheria toxoids (DTaP) have been tested in European trials and compared with whole-cell diphtheria, tetanus, and pertussis (DTP) preparations. The results of most trials have been released to the press and formal manuscripts will be published in scientific journals within the next few weeks.1-3 The data from these studies indicate variable efficacy of both acellular and whole-cell pertussis vaccines, reflecting differences in manufacturing processes and the number and type of vaccine components in the new acellular vaccines.
In-Hospital Mortality for Surgical Repair of Congenital Heart Defects: Preliminary Observations of Variation by Hospital Caseload
Authors: Fulton David R. , Geggel Robert L.
Published: December 2021

The article by Jenkins et al (Pediatrics. 1995:95:323-330) purports to show that children operated on at hospitals performing higher volumes of surgery have a greater likelihood of survival than those having surgery at lower volume institutions. The study is seriously flawed by their own admission. Information was obtained retrospectively from statewide databases compiled from (ICD-9-CM) discharge and procedure codes, which relied on medical record coding of questionable completeness and quality. There was limited or absent information regarding the clinical conditions of individual patients.
Letters to the Editor
Authors: Kohrman Arthur F. , Frader Joel
Published: December 2021

We thank Dr Bartholome for his response to the publication of the AAP statement entitled Informed Consent, Parental Permission, and Assent in Pediatric Practice. We applaud the conviction and clarity with which he states his position that those who care for children often do not accord them sufficient respect as persons in their own right. Indeed, the Committee on Bioethics' statement itself and the growing awareness in the pediatric community of our responsibility to give children voice in decisions concerning their health care owe a great debt to Dr Bartholome's vision, tenacity, and persuasion.
Sudden Infant Death Syndrome in Relation to Weather and Optimetrically Measured Air Pollution in Taiwan
Authors: Knöbel Harald H. , Chen Chien-Jen , Liang Kung-Yee
Published: December 2021

Objective. To examine the possible role of weather and air pollution in sudden infant death syndrome (SIDS) and suffocation.

Methods. Poisson regression analysis was carried out to measure the association between daily rates of SIDS per 1000 live births and daily average values of visibility and temperature in Taiwan between 1981 and 1991. The optimetrical measure of air pollution was used to represent pollution over a whole area rather than at a point source.

Results. Mortality from SIDS per 1000 live births was 3.3 times greater in the lowest category of visibility on the day of death than in the highest category; this rate ratio was 3.4 for the average visibility during the 9 days before death. Adjustment for population size, season, level of urbanization, incidence of deaths from respiratory tract infections, temperature, air pressure, sunshine, rainfall, relative humidity, and windspeed increased these rate ratios to 3.8 and 5.1, respectively. This suggests that the relationship between air pollution and SIDS is not biased by ecological confounders. For temperature the rate ratios were between 3.3 and 4.0.

Conclusions. Our findings confirm the association of climatic temperature and air pollution with SIDS.
Continuing Risk for Hepatitis B Virus Transmission Among Southeast Asian Infants in Louisiana
Authors: Mahoney Francis J. , Lawrence Margaret , Scott Cathy , Le Quan , Lambert Steve , Farley Thomas A.
Published: December 2021

Objective. Implementation and evaluation of a hepatitis B vaccination program for Southeast Asian infants in Louisiana.

Methods. A baseline seroprevalence survey of hepatitis B virus (HBV) infection in US-born Southeast Asian children was conducted in 1991 before the implementation of a vaccination program. Hepatitis B vaccination and postvaccination serologic testing of survey participants 10 years of age and younger was performed. Eighteen months after the hepatitis B vaccine was integrated into infant immunization schedules in July 1993, a vaccination coverage survey was performed.

Results. Baseline serologic testing was conducted on 96% of persons from 225 randomly selected households in a Southeast Asian community in Louisiana. Of 676 US-born children, 28 (4.1%) had chronic HBV infection; 61% of children with chronic HBV infection were born to hepatitis B surface antigen (HBsAg)-negative women. Among children born to HBsAg-negative women, the prevalence of chronic HBV infection increased with age, reaching 7.3% for children 13 to 16 years of age. Children born to HBsAg-negative women and living with carriers were 5.4 times more likely to have evidence of HBV infection than were children who did not live with carriers. Before the survey, only one child had received three doses of hepatitis B vaccine. In July 1993, 43% of Southeast Asian infants 9 to 18 months of age born in Louisiana had received three doses of hepatitis B vaccine. Infants who received immunizations from private providers were more likely to be fully vaccinated than were infants who received services from public sector clinics (prevalence ratio, 2.1; 95% confidence interval, 1.4,3.1).

Conclusions. HBV transmission occurs throughout childhood in US-born Southeast Asian children, and the prevalence of chronic HBV infection approaches that of the country of origin. Few US-born Southeast Asian children have received hepatitis B vaccine. Because of the high rates of early childhood HBV transmission and the high risk of chronic infection in Asian and Pacific Islander communities, prevention efforts should be enhanced to ensure that all Asian and Pacific Islander infants receive hepatitis B vaccine in the first 12 months of life and that older children are vaccinated.
Serologic Responses to Bartonella and Afipia Antigens in Patients With Cat Scratch Disease
Authors: Szelc-Kelly Cynthia M. , Goral Simin , Perez-Perez Guillermo I. , Perkins Bradley A. , Regnery Russell L. , Edwards Kathryn M.
Published: December 2021

Objective. To assess the serologic response to Afipia and Bartonella, previously named Rochalimaea, in patients with cat scratch disease (CSD) and a healthy control group.

Design. Prospective, controlled trial.

Setting. Referral clinic and hospitalized patients in a university medical center.

Participants. Eighty patients with CSD and 57 healthy control subjects of similar age.

Main Outcome Measures. The immune responses to Afipia felis and Bartonella henselae were evaluated by a newly developed enzyme-linked immunosorbent assay (ELISA) in patients with CSD and healthy control subjects. Responses to B henselae were also measured by indirect fluorescent antibody (IFA) tests. Antibody levels to Bartonella quintana were measured by ELISA and IFA in a limited number of patients and control subjects.

Results. Of the 80 patients with clinical CSD, 56 had positive results of CSD skin tests. ELISA antibody levels to A felis did not differ between patients and control subjects, but immunoglobulin M (IgM) and IgG ELISA antibodies to B henselae and B quintana were significantly higher in patients than in control subjects. IFA responses to B henselae and B quintana were also significantly higher in patients than in control subjects.

Conclusion. Patients with CSD had significant serologic responses to B henselae and B quintana but not to A felis, suggesting that the causative agent of CSD is antigenically related to the Bartonella genus and not to Afipia. The Bartonella IgM ELISA and IFA assay were both sensitive and specific and may be used to establish the diagnosis of CSD.
Can Pediatric Training Manage in Managed Care?
Authors: Leslie Laurel K.
Published: December 2021

On January 18, 1995, the University of California convened a special meeting to discuss the business operations of its five academic medical centers in San Francisco, Sacramento, San Diego, Los Angeles, and Irvine. Because of the rapid developments occurring in the maturing and competitive managed care market in California, the academic medical centers are facing unprecedented financial pressures. Charles Townsend, of the accounting firm KPMG Peat Marwick, stated that the medical centers' staff would need to be cut by at least 2500 full-time equivalents, including physicians and nurses, by the year 1999. William Kerr, Director of the University of California San Francisco Medical Center, forecasted a comprehensive restructuring and streamlining of services. Jordan Cohen, president of the Association of American Medical Colleges, described the challenges facing these five academic medical centers and others like them as "truly seismic."1

The rise of managed care medical systems during the last 5 years has led many researchers to question whether the academic medical center will survive in its current state.2-6 Market forces are changing the provision of medical care at an extremely fast pace. By 1998, an estimated 60% of people living in US cities will be covered by managed care health plans. Fewer hospital admissions, shorter hospital stays, and decreased reimbursements associated with managed care have decreased hospitals' operating gains. Academic medical centers, such as those in California, are facing pressure to lower health care delivery costs. The probable decreases in Medicare and research funds under the current Congress also threaten the financial revenues of academic medical centers.
Inhaled Nitric Oxide for Persistent Pulmonary Hypertension of the Newborn: The Physiology Matters
Authors: Abman Steven H. , Kinsella John P.
Published: December 2021

The ability of inhaled nitric oxide (iNO) to acutely lower pulmonary vascular resistance (PVR) and improve oxygenation in diverse clinical settings suggests that iNO therapy may provide a unique tool to expand our current armamentariurn in treating various cardiopulmonary disorders, including persistent pulmonary hypertension of the newborn (PPHN). Treatment of severe PPHN has been limited in part by the lack of a selective pulmonary vasodilator that effectively lowers PVR without adverse effects on systemic arterial pressure, cardiac performance, or intrapulmonary shunt. In 1992, two articles were published in Lancet which reported that iNO can improve oxygenation in neonates with severe PPHN without lowering systemic pressure.1,2
The Progression of Human Papillomavirus Lesions in Sexual Assault Victims
Authors: Kellogg Nancy D. , Parra Juan M.
Published: December 2021

Human papillomavirus (HPV) infections are seen in up to 15% of adolescents who present to a gynecology clinic.1 Anogenital HPV develops in some adolescents as a result of sexual assault. Sexual sault protocols address detection and follow-up for chlamydia, gonorrhea, syphilis, human immunodeficiency virus (HIV) and hepatitis, 2,3 but follow-up for detection of HPV lesions is not formally addressed. Early detection of HPV lesions is important for treatment and long-term management, because subtypes 6, 10, 11, 16, 18, 31, 33, and 35 have been associated with cervical cancer.4 Although 6 and 11 are the most common subtypes found in condylomata acuminata, types 1, 2, 10, 16, and 18 are also found in anogenital lesions.5
Headband Alopecia
Authors: Marino Ronald V.
Published: December 2021

Alopecia is a common concern among parents of young infants. Transient universal hair thinning or loss during the first months of life, known as telogen effluvium, is common. As the hair usually grows back in the ensuing months, reassurance and nonintervention are appropriate. Traumatic alopecia occurs in response to traction, pressure, friction, or physical trauma. Infants who spend a great deal of time on their backs experience occipital hair loss. Hair styles utilizing tight braids or barrettes may induce traction alopecia.
Letters to the Editor
Authors: Hunt Patricia A. , Pellock John M.
Published: December 2021

The report of a study of 47 children by Freeman et al1 indicated administration of carnitine did not significantly improve symptoms associated with the anticonvulsant medications valproic acid and carbamazepine. Further study has been recommended to validate the clinical impression of some workers that therapeutic carnitine may be beneficial for some patients with low carnitine levels.2 Recent experience at a large residential training and treatment center for the mentally retarded provides further pertinent information.

At Southside Virginia Training Center for the mentally retarded in Petersburg, Virginia, 40% of the residents received anticonvulsant medication for epilepsy.
Letters to the Editor
Authors: Freeman John M.
Published: December 2021

We read with interest the report of Drs Hunt and Pellock on screening a population of institutionalized patients for carnitine deficiency. There did not appear to be any substantial correlation between the carnitine levels and the patient's function, handicap, or the ingestion of anticonvulsants. This population could be useful for a blinded test of the reported beneficial effects of carnitine administration.

The letter from Sigma-Tau Pharmaceuticals, manufacturers of Carnitor, is, I believe, an intentionally misleading and disingenuous extension of their advertising campaign of which my quote is the opening sentence.
Correct Dosing of Vancomycin in Infants and Children
Authors: Logsdon Beth A. , Lee Kelley R. , Barrett Fred F.
Published: December 2021

In accordance with the recent Centers for Disease Control and Prevention guidelines for the use of vancomycin,1 we began uating the indications and dose of vancomycin IV used in our institution. We discovered a large amount of incorrect dosing of vancomycin in infants and children with 30 mg/kg/day (10 mg/kg q8h). This dose has been traced to The Harriet Lane Handbook, 13th edition.2 However, all the references listed in Harriet Lane on page 561 recommend the standard dosing of vancomycin, 40 mg/kg/day (10 mg/kg q6h).
Description and Evaluation of Serologic Assays Used in a Multicenter Trial of Acellular Pertussis Vaccines
Authors: Meade Bruce D. , Deforest Adamadia , Edwards Kathyrn M. , Romani Theresa A. , Lynn Freyja , O'Brien Colleen H. , Swartz Christina B. , Reed George F. , Deloria Maria A.
Published: December 2021

In the September 1995 supplement, titled Report of the Nationwide Multicenter Acellular Pertussis Trial (1995;96:547-603), two articles contain errors:

• Description and Evaluation of Serologic Assays Used in a Multicenter Trial of Acellular Pertussis Vaccines (1995;96:570-575): On page 571, the 14th line under the heading "ELISA" contains an incorrect percentage for Tween-20 in the serum incubation buffer. It should be 0.05% (vol/vol) Tween-20, not 0.5%, as printed.
MERGERS CHANGE U.S. HEALTH CARE SYSTEM; MANY QUESTIONS LIE AHEAD
Authors: L. J. F.
Published: December 2021

In 1994, publicly traded HMOs completed 13 acquisitions valued at over $4 billion. Two hospital chains, Columbia/HCA and National Medical Enterprises, recently completed mergers that give them ownership of 61% of the for-profit hospital beds in the United States. The Wall Street Journal predicts that within a year 10 publicly traded physician practice companies will be competing for a potential $200 billion market. Such concentrated market power could make the health care system more efficient—and less expensive—or, paradoxically, could produce higher prices and fewer choices for consumers.
Letter To The Editor
Authors: Adams Joyce A.
Published: December 2021

I would like to attempt to allay the concerns expressed by Drs Hobbs and Wynne over the results of our study on the frequency of abnormal anogenital findings in children whose perpetrators were convicted of molestation.1

First of all, perhaps an explanation of the patient population served by the Sexual Abuse Evaluation Program at Valley Medical Center is in order. Like many programs in the United States, we saw children who were referred for evaluation after they had disclosed their abuse and had been evaluated by the child protection agencies.
Physician Experience With Pediatric Inpatient Care in Washington State
Authors: Melzer Sanford M. , Grossman David C. , Rivara Frederick P.
Published: December 2021

Objective. To determine the frequency with which pediatricians and family physicians in Washington State serve as attending physicians for pediatric inpatients.

Design. Retrospective review of statewide hospital discharge data.

Subjects. Attending physicians for all patients younger than 18 years of age with nonsurgical diagnoses discharged from civilian hospitals in Washington State during 1989 and 1990.

Results. Using medical rosters, the self-identified specialty of the attending physician was determined for 93% (n = 181 581) of discharges. Pediatricians and family physicians were listed as attending for 61% and 28%, respectively, of all eligible patients. Statewide, 97% (n = 555) of all pediatricians and 86% (n = 939) of all family physicians served as attending physicians for at least one inpatient, including healthy newborns, during the 2-year study period. The median annual number of discharges per physician was 78 for pediatricians and 14.5 for family physicians. Excluding healthy newborns, the median annual number of discharges was 25 for pediatricians and 3 for family physicians. Five percent of the physician attending group provided inpatient care for 50% of all children hospitalized with diagnoses other than healthy newborn; 50% of attending physicians cared for 95% of the patients. In rural hospitals, where family physicians served as attending physicians for 44% of pediatric inpatients, children were 3.3 times more likely to receive their care from family physicians than those hospitalized in urban centers.

Conclusions. Most pediatricians and family physicians serve as inpatient attending physicians for hospitalized children only infrequently. These findings question whether the emphasis on inpatient care in many pediatric and family medicine training programs remains an appropriate goal.
MORE BLIND CHILDREN?
Authors: Student
Published: December 2021

Directors of blind children's centers in Phoenix, San Francisco, Boston, Los Angeles, and other cities report increased enrollments because of retinopathy of prematurity (ROP) and cortical visual impairment, but there is no official tracking or registry of blind children nationwide ...
Calf Blood Pressure: Clinical Implications and Correlations With Arm Blood Pressure in Infants and Young Children
Authors: Crapanzano Michael S. , Strong William B. , Newman Ingrid R. , Hixon R. Lester , Casal Devarra , Linder Charles W.
Published: December 2021

Objective. Indirect measurement of lower extremity blood pressure is often used in the clinical setting, although normative data after the newborn period are not readily available.

Methods. Indirect blood pressure (BP) measurement was obtained in the right arms and right calves of 148 healthy infants and young children 2 weeks to 3 years of age. All measurements were made using an oscillometric device. The infants and children were quiet or asleep and in the supine position. A BP cuff of proper size was chosen. Three measurements were made in both extremities; the average of the second and third measurements was used for all analyses.

Results. Age correlated better with calf systolic blood pressure (SBPc) than with arm SBP (SBPa) (r = .52 vs .17). Calf diastolic blood pressure (DBPc) and calf mean blood pressure (MBPc) correlated moderately poorly with age (r = .37 and .39, respectively). There was no order effect. SBPc correlated best with height (r .53), then age (r = .52), and, finally, weight (r = .51). The correlation between BPc and BPa was moderately low. The correlation of SBPc with SBPa was r = .46; that of DBPc with DBPa was r = .37; and that of MBPc with MBPa was r = .41. From birth to 6 months, SBPc was slightly lower than SBPa (1 to 3 mm Hg). SBPc increased linearly relative to SBPa and began to exceed SBPa at 6 months of age. The pattern of DBP and MBP was similar. Wide variability of blood pressure parameters was noted between the infants and children at all ages.

Conclusions. Reference data are presented for BPc and the difference between BPc and BPa in healthy infants and children from 2 weeks to 3 years of age. BPc is not equivalent to BPa and should not be arbitrarily substituted. Because of the wide variability among healthy infants and children, SBPc measurements should be interpreted with caution when evaluating for coarctation of the aorta.
Amyoplasia, the Most Common Type of Arthrogryposis: The Potential for Good Outcome
Authors: Sells Jill M. , Jaffe Kenneth M. , Hall Judith G.
Published: December 2021

Background. Amyoplasia is the most commonly seen diagnostic subgroup of children with arthrogryposis. The natural history of these children has not been well described previously.

Methods. Review of the medical records of 38 children with amyoplasia enabled us to describe their birth characteristics, therapeutic interventions, and functional outcomes.

Results. Eighty-four percent of the children had symmetrical, four-limb involvement, which was similar to the original descriptions of amyoplasia, at birth. There was an average of 5.7 orthopedic procedures per child, and the children had multiple castings and splintings of their limbs and participated in physical and occupational therapy on a regular basis. By the age of 5 years, 85% were ambulatory, most were relatively or completely independent in their activities of daily living, and most were in regular classrooms at the appropriate grade level.

Conclusion. Although children with amyoplasia have pronounced musculoskeletal involvement at birth, which requires orthopedic and rehabilitative interventions during their childhood, their functional outcome in both physical and educational areas is excellent.
Effectiveness of Vaccination at 6 to 11 Months of Age During an Outbreak of Measles
Authors: De Serres Gaston , Boulianne Nicole , Ratnam Sam , Corriveau André
Published: December 2021

Hypothesis. Monovalent measles vaccine can be administered to children 6 to 11 months of age during an outbreak. Efficacy and effectiveness of this control measure still have to be assessed.

Methods. During an outbreak of measles, monovalent measles vaccine was administered as part of outbreak control to children aged 6 to 11 months. Active surveillance was used to detect cases of measles occurring during the following month. Children who did not develop measles were tested for measles antibody before their revaccination at 15 months of age.

Results. Of 81 children 6 to 11 months of age, 56 were vaccinated and two received immunoglobulins; the latter were excluded from the analysis. Measles occurred in 15 of the 79 children during and after the vaccination campaign, for an overall attack rate of 19%. The attack rate among unvaccinated children was 39% (9 of 23), compared with 11% (6 of 56) among those vaccinated (relative risk = 3.6, 95% confidence interval [CI] = 1.5 to 9.1). All of those who sustained measles in the vaccinated group developed the disease within 10 days after vaccination. The overall vaccine effectiveness was 73% (95% CI = 32% to 89%) when children were classified as vaccinated as soon as they were given measles vaccine. It rose to 96% (95% CI = 72% to 99%) when children were considered vaccinated 1 week postimmunization. Nineteen infants who were vaccinated and who did not develop measles during the outbreak were tested for measles antibody status at 15 months of age before revaccination. All had plaque reduction neutralizing antibody titers greater than 120.

Conclusion.This study confirms that measles vaccination of infants aged 6 to 11 months is an effective intervention measure during measles outbreaks.
JUNK SCIENCE IS DRIVING US CRAZY
Authors: Student
Published: December 2021

A spermicide used with most barrier contraceptives causes birth defects; the whooping cough vaccine causes brain damage; incompetence by obstetricians is a leading cause of cerebral palsy; the morning sickness drug Debendox caused an epidemic of birth defects; environmental pollutants cause chemically-induced AIDS. All of these stories have been reported and all are false. But, as Peter Huber wrote in Galileo's Revenge: Junk Science in the Court Room, they were not reported only in the gutter press and on the TV mid-day quasi documentaries; they were reported in the annals of U.S. and U.K. jurisprudence. One amazing case was a successful $1 million award to a soothsayer who, with expert testimony supporting her, claimed that a CAT scan had removed her psychic powers. Imagine that epidemiological study we would need to do to prove that one! Imagine the debate over the outcome measures!
Cutaneous Necrosis After Contact With Calcium Chloride: A Mistaken Diagnosis of Child Abuse
Authors: ZURBUCHEN PHILIPPE , LECOULTRE CLAUDE , CALZA ANNE-MARIE , HALPÉRIN DANIEL S.
Published: December 2021

Necrosis of the skin after contact with calcium chloride has been described in a variety of situations, including that of oil field workers and prolonged electroencephalographic testing (contact paste). Circumscribed dystrophic dermal calcification was reported for the first time in 1935 and may follow the application of dry calcium or calcium-containing solutions. The authors report a case of percutaneous penetration of a defrosting, industrial calcium salt, which was followed by deep-dermal thigh necrosis in a child. This uncommon injury raised concern about child abuse.
Neuroblastoma and Congenital Cardiovascular Malformations
Authors: ROSTI LUCA , LIN ANGELA E. , FRIGIOLA ALESSANDRO
Published: December 2021

Congenital cardiovascular malformations (CCVM) are frequently associated with noncardiac malformations, often comprising a multiple malformation syndrome, but occurring infrequently in nonsyndromic systemic disease states such as neuroblastoma. As the most common malignancy in the first year of life, neuroblastoma presents as both clinically apparent and clinically unsuspected in situ tumors detected at autopsy. Neuroblastoma's association with CCVMs, especially conotruncal defects, suggests a possible common embryologic role for abnormal neural crest cell migration and development. We provide further documentation of this intriguing, albeit rare, association by reporting a boy with a prenatally detected complex CCVM (univentricular heart and dextro-transposition of the great arteries [d-TGA]) and congenital neuroblastoma.
Condom Availability for Youth: A High-risk Alternative
Authors: FRIEDMAN ZELIG , TRIVELLI LILIANA
Published: December 2021

New York State Regulations require that "any written or oral instruction relating to condoms must fully and clearly disclose the various risks and consequences of condom failure." The New York City HIV/AIDS Advisory Council to the Board of Education, of which we are members, must see that the educational material complies with this regulation. This means that students learn a lot more than "condoms are not 100% safe." Ninth graders and up learn over 20 precautions to take, including the 13 steps involved in proper condom use.
Tetracaine, Adrenaline, and Cocaine (TAC) Confusion
Authors: BISCHOF RALPH O.
Published: December 2021

I would like to call attention to a potential problem with the use of the term "TAC gel." In the recently published study by Ernst et al,"TAC gel" refers to a topical anesthetic formulation consisting of the active ingredients tetracaine, adrenaline, and cocaine. A literature search showed that the use of this term for a topical anesthetic gel appears to originate with a paper published in 1992. However, the name already was in use for a different product.
Rapid Streptococcal Tests
Authors: RAVENEL S. DUBOSE , ELLIS GREGORY CARL , MICHAL WILLIAM N.
Published: December 2021

Roddey et al have reported an important study on the sensitivity and specificity of the Strep A OIA test compared with two culture techniques—5% sheep blood agar and Todd-Hewitt broth—in an office practice setting. They found the sensitivity and specificity of OIA as compared with sheep blood culture to be 91.4% and 95.6%, and compared with the broth method, 90.4% and 94.1%, respectively. They conclude that the OIA method is preferable for the majority of their patients, but recommend a throat culture be performed in cases with a negative OIA test.
Melatonin for Insomnia and Jet Lag
Authors: TUROW VICTOR
Published: December 2021

Recently, an adolescent patient, in for a routine physical examination, asked about the use of melatonin for insomnia. She had actually purchased a melatonin-containing product several weeks before at a local health food store, dosing herself nightly as instructed by the "guy behind the counter." Several other patients and parents have since inquired about my knowledge of this "natural remedy."

The body's internal clock, the circadian system, is regulated by the pineal gland.
Preliminary Experience With Intestinal Transplantation in Infants and Children
Authors: Langnas Alan N. , Shaw B. W. , Antonson Dean L. , Kaufman Stuart S. , Mack David R. , Heffron Thomas G. , Fox Ira J. , Vanderhoof Jon A.
Published: December 2021

Objective. This report discusses the preliminary experience with intestinal transplantation in children at the University of Nebraska Medical Center.

Patients. During the past 4 years, 16 intestinal transplants have been performed in infants and children. Thirteen have been combined liver and bowel transplants, and the remainder were isolated intestinal transplants. Nearly half of the patients were younger than 1 year of age at the time of surgery, and the vast majority were younger than 5 years of age. All but one had short bowel syndrome.

Results. The 1-year actuarial patient and graft survival rates for recipients of liver and small bowel transplants were 76% and 61%, respectively. Eight of 13 patients who received liver and small bowel transplants remain alive at the time of this writing, with a mean length of follow-up of 263 (range, 7 to 1223) days. Six patients are currently free of total parenteral nutrition. All three patients receiving isolated intestinal transplants are alive and free of parenteral nutrition. The mean length of follow-up is 384 (range, 330 to 450) days. Major complications have included severe infections and rejection. Lymphoproliferative disease, graft-versus-host disease, and chylous ascites have not been major problems.

Conclusions. Although intestinal transplantation is in its infancy, these preliminary results suggest combined liver and bowel transplants and isolated intestinal transplantation may be viable options for some patients with intestinal failure caused by short bowel syndrome or other gastrointestinal disease in whom long-term total parenteral nutrition is not an attractive option.
Can Asphyxiated Infants at Risk for Neonatal Seizures Be Rapidly Identified by Current High-risk Markers?
Authors: Perlman Jeffrey M. , Risser Rick
Published: December 2021

Objective. Markers currently used to identify infants at highest risk for perinatal hypoxicischemic cerebral injury are insensitive in predicting the subsequent occurrence of neonatal seizures and/or neurodevelopmental sequelae, ie, cerebral palsy. To facilitate therapeutic strategies, early identification of the infant at highest risk for developing seizures secondary to hypoxia ischemia or asphyxia is critical, particularly if novel but potentially toxic therapies currently under experimental investigation become available for clinical use.

Methods. Ninety-six inborn term infants considered at high risk for having neonatal seizures secondary to hypoxia ischemia or asphyxia and admitted to the neonatal intensive care unit directly after labor and delivery were prospectively evaluated. Markers of high risk included the presence of moderate to thick meconiumstained amniotic fluid (MSAF), fetal heart rate (FHRT) abnormalities abruptio placentae, intubation and positive pressure ventilation in the delivery room (DR), chest compressions and epinephrine administration as part of resuscitation, a 5-minute Apgar score of 5 or less, umbilical cord arterial pH of 7.00 or less, and/or a base deficit of -14 mEq/L or more negative.

Results. Seizures developed in 5 (5.2%) of the 96 infants. High-risk markers included FHRT abnormalities only (n = 36), FHRT abnormalities and MSAF (n = 20), MSAF only (n = 23), abruptio placentae (n = 6), intubation in the DR (n = 44), intubation in the neonatal intensive care unit (n = 22), chest compressions (n = 2), 5-minute Apgar scores of 5 or less (n = 21), umbilical cord arterial pH of 7.00 or less (n = 21), and base deficits of -14 mEq/L or more negative (n = 19). By univariate analysis, significant relationships with seizures were found with Apgar scores, the need for intubation in the DR, umbilical cord arterial pH, and base deficit. Combinations of the identified risk markers showed a strong relationship with seizures with the following odds ratios (ORs), 95% confidence limits, sensitivity, specificity, and positive predictive values (PPVs): (1) low cord pH and intubation, OR, 163 (confidence limits, 7.9 and 3343.7); sensitivity, 100%; specificity 94%; and PPV, 50%; (2) low cord pH and low 5-minute Apgar score, OR, 39 (confidence limits, 3.9 and 392.5); sensitivity, 80%; specificity, 91%; and PPV, 33.3%; and (3) low pH, intubation, and low 5-minute Apgar score, OR, 340 (confidence limits, 17.8 and 6480.6); sensitivity, 80%; specificity, 98.8%; and PPV, 80%.

Conclusions. A combination of high-risk postnatal markers, specifically, a low 5-minute Apgar score and intubation in the DR in association with severe fetal acidemia, facilitates the identification within the first hour of life of term infants at highest risk for developing seizures secondary to perinatal asphyxia.
The Efficacy of Nebulized Budesonide in Dexamethasone-treated Outpatients With Croup
Authors: Klassen Terry P. , Watters Lise K. , Feldman Mark E. , Sutcliffe Teresa , Rowe Peter C.
Published: December 2021

Objective. To determine the added clinical benefit of nebulized budesonide in children with mild to moderate croup treated with 0.6 mg/kg oral dexamethasone.

Design. Randomized, double-blind, placebo-controlled trial.

Setting. Emergency department of a tertiary-care pediatric hospital with 47 000 visits per year.

Participants. Children 3 months to 5 years of age with a syndrome consisting of hoarseness, inspiratory stridor, and barking cough and a croup score of 3 or greater after at least 15 minutes of mist therapy. Patients were excluded from the study if they had diagnoses of epiglottitis, chronic upper or lower airway disease (not including asthma), or severe croup or had received corticosteroids within the preceding 2 weeks.

Intervention. All patients received 0.6 mg/kg oral dexamethasone and were randomly assigned to receive 4 mL (2 mg) of budesonide solution (n = 25) or 4 mL of 0.9% saline solution (n = 25) by updraft nebulizer with a continuous flow of oxygen at 5 to 6 L/min.

Main Outcome Measures. The primary outcome measure was the proportion of patients in each group who had clinically important changes (two points) in the croup score during the 4 hours after treatment.

Results. Eighty-four percent (n = 21) of the patients who received budesonide had clinically important responses, compared with 56% (n = 14) in the placebo group. The number of patients who would need to be treated with nebulized budesonide for one patient to have a clinically important response is four patients.

Conclusions. Despite receiving simultaneous oral dexamethasone, pediatric outpatients with mild to moderate croup have added, clinically important improvement in respiratory symptoms after treatment with budesonide.