bluuebunny/crossref_metadata_2025 huggingface dataset:
Training Pediatricians for the Evolving Generalist–Specialist Interface in the Managed Care Era
Authors: Williams Roberta G. , Stein Leonard D. , Leslie Laurel K.
Published: December 2021

Managed care involves the linkage of service delivery and financing. One of the outgrowths of the rapid expansion of managed care over the past decade has been an increasing consensus that the generalist of the future will need to manage more of the patients traditionally cared for by subspecialists. Subspecialty education for pediatric residents becomes increasingly important as the role of the pediatric generalist enlarges to include independent outpatient management of some less complex but traditional subspecialty patients as well as collaborative management of more complex patients. To prepare for this role, a balanced exposure to subspecialty problems in outpatient as well as inpatient settings is required. At the same time, however, the growth of managed care has led to certain barriers for providing this enhanced training. This article describes the effects of managed care on the role and scope of the pediatric subspecialist as well as on educational strategies for coping with these changes while reshaping the roles of both generalists and subspecialists for maximal effectiveness in meeting the health care needs of children.
Growth Hormone Stimulation Test Results as Predictors of Recombinant Human Growth Hormone Treatment Outcomes: Preliminary Analysis of the National Cooperative Growth Study Database
Authors: Bright George M. , Julius Joanne R. , Lima John , Blethen Sandra L.
Published: December 2021

Growth hormone (GH) stimulation tests are considered a prerequisite to clinical trials of recombinant human GH (rhGH) therapy, but the test results may not be predictive of the treatment outcomes with rhGH. We examined the GH stimulation test results as a predictor of the treatment outcome in a cohort of prepubertal subjects in the National Cooperative Growth Study. A standard is proposed in which a diagnosis of GH deficiency is considered appropriate when a patient has significant first-year catch-up growth and that a positive stimulation test result predicts this outcome. With this construct, a traditional interpretation of GH stimulation test results correctly identifies 64% of the rhGH treatment outcomes. The analysis shows an upper limit of diagnostic sensitivity of 82% and a lower limit of specificity of 25% in our study population. The results of our recent studies suggest that the sensitivity and specificity of the current GH stimulation tests are attributable in part to broad intersubject variation in GH clearance, rates of GH elimination, and GH volume of distribution. The combined studies suggest that the use of subject-specific pharmacokinetic parameters will improve the diagnostic interpretation of GH stimulation test results and improve rhGH treatment outcomes. growth hormone stimulation tests, recombinant human growth hormone, pharmacokinetic parameters, maximal stimulated growth hormone concentration.
Analysis of Bone Age Data From National Cooperative Growth Study Substudy VII
Authors: Kemp Stephen F. , Sy Judy P.
Published: December 2021

National Cooperative Growth Study substudy VII was conducted 1) to compare standardized hand–wrist and knee bone age determinations in pubertal children treated with growth hormone (GH); 2) to compare local determinations of bone ages with centrally determined bone ages; 3) to relate the response to GH therapy to the bone age determinations; and 4) to ascertain the predictive value of each type of bone age determination. Eligible subjects were those in the National Cooperative Growth Study who were at Tanner pubertal stage 2 or greater for breasts (girls) or genitals (boys). Radiographs of the hand–wrist were taken annually, and radiographs of the knee were taken at the beginning and the end of the study. Separate bone age determinations were made from these radiographs. A combined hand–wrist and knee bone age determination also was derived. There were 990 patients in the study; in 925 (677 boys), there were both hand–wrist and knee bone age determinations from the baseline pubertal radiographs. There was only one radiographic assessment in 496 patients, two in 205 patients, and three to eight in the remaining patients. The strongest correlation was between the hand–wrist bone age and the hand–wrist plus knee bone age (r = .995). Also strongly correlated were knee with hand–wrist (r = .872) and knee with hand–wrist plus knee (r = .914). For none of these bone age methods was any statistically significant difference found between the methods. The locally determined bone ages correlated strongly with the centrally determined bone ages for knee (r = .850), hand–wrist (r = .928), and hand–wrist plus knee (r = .930); however, the locally determined knee and hand–wrist values were less (by ∼0.3 year) than the centrally determined values. These differences, however, do not appear to be clinically significant.
Round Table Discussion
Authors: DORFMAN ALBERT , ROTHMAN STEPHEN , POTTS ALBERT , BACON J. E. , HARPER EDWIN A.
Published: December 2021

Chairman Dorfman: We thought that this subject was so broad and had so many ramifications that an attempt at complete coverage would result in nothing but a listing of the diseases in which ACTH and cortisone have been used. Therefore, it would seem instead worth while to consider general problems relating to ACTH and cortisone and then proceed to a discussion of a limited number of diseases. It is going to be difficult for us to give an expert opinion on every possible phase of this subject.

We should consider first of all: (1) What type of therapy these drugs represent and (2) how the effects observed relate to the pathogenesis of the diseases in question. When the announcement of the effect of ACTH and cortisone was made in 1949, they were heralded widely by many people as a new approach to the disease state and consequently these agents were studied in a wide variety of apparently unrelated diseases. Originally there was great enthusiasm. I can recall attending the first Armour conference; it was more like attending a meeting of a mystic cult than a scientific meeting. Everybody arose and shouted, "I, too, have seen the miracle!"

Since that time investigators have come to a more careful assessment of the usefulness of these drugs. We now are in the process of a swing toward a more pessimistic viewpoint, with some people saying, "they are not any good for anything, they are just poison and shouldn't be used at all." Most people who have thought about the problem feel that the truth lies somewhere between the extremes. ACTH and cortisone are not effective in all diseases.
CHANGING PATTERNS OF RESPIRATION IN NEWBORN INFANTS
Authors: MILLER HERBERT C. , BEHRLE FRANKLIN C.
Published: December 2021

The respiratory activity of quiet and sleeping healthy infants has been studied by pneumographic tracings and by clinical observations. Four successive stages of respiration have been described through which all healthy, full term newborn infants pass.

The first stage is concerned with the establishment of postnatal respirations and lasts for a few minutes following birth.

The second stage lasts from several hours to a day or more. Respiratory activity is characterized by a wide range of rates, a regular rhythm and a single respiratory pattern, to which the term "synchronous" has been given. The term is based on the fact that all parts of the chest and abdomen expand and contract together in an easy, smooth and regular fashion. Any signs of chest retraction indicate that the infant either is not well or has passed into the third stage.

The third stage lasts several days or weeks. Infants in this stage exhibit rapidly fluctuating rates, variable rhythms and a wide variety of respiratory patterns. Two of the common patterns seen in this stage have been given the terms "simple retraction" and "see-saw." In simple retraction the lower end of the sternum and adjacent costal margins are pulled inwards as the abdomen and upper chest expand. In "see-saw" breathing the whole anterior chest wall is pulled inwards and downwards as the abdomen expands. There is much shifting back and forth from one pattern to another.

The fourth stage begins several weeks after birth and is characterized by a return to more stable rhythms and respiratory patterns. All previous bizarre patterns have disappeared leaving "synchronous" and "simple retraction" as the only patterns of breathing.

The same four stages of respiration have been identified in a small group of surviving premature infants.

Knowledge of these stages has made it possible to give a more accurate prognosis during the first 24 hours of life on the infant's chances for survival The absence of retraction during stage 2 has been associated with an excellent prognosis for the infant. The presence of any degree of retraction in the first 24 hours of life, except as it may occur in the first few minutes after birth, has been associated with serious illnesses in the infants in the small series of cases observed to date.

Factors which might explain the presence of stages 2, 3 and 4 have been explored only partially. One of the factors involved in the change from stages 2 to 3 is the increasing vigor of diaphragmatic contractions.
STUDIES OF THE IMMUNOLOGY OF THE NEWBORN INFANT
Authors: DANCIS JOSEPH , OSBORN JOHN J. , KUNZ HANS W.
Published: December 2021

The antibody response of premature infants immunized at birth with a single injection of diphtheria toxoid was compared to that of a group of term infants similarly immunized. No significant difference was demonstrated.

A group of premature infants was immunized about the time that was estimated to be their normal birth date and the antibody response compared to that of term infants at birth. The performance of the premature infants was superior to that of the term infants.

The significance of these findings is discussed.
LYMPHOID HYPERPLASIA OF THE APPENDIX
Authors: NATHANS ALFRED A. , MERENSTEIN HYMAN , BROWN SAMUEL S.
Published: December 2021

One hundred ninety-eight cases of lymphoid hyperplasia of the appendix, some of which had other associated pathology, have been analyzed.

Comparison has been made with an analogous series of acute appendicitis in children.

There is no precise differential diagnosis between acute appendicitis and lymphoid hyperplasia of the appendix. Each case has to be watched carefully, and any increase in local signs is an indication for surgery.

Lymphoid hyperplasia is frequently the precursor of acute appendicitis.
MUCOLYTIC ENZYME SYSTEMS
Authors: GOOD ROBERT A. , KELLEY VINCENT C. , GOOD THOMAS A. , GLICK DAVID
Published: December 2021

Normal maternal serum and newborn infant serum have been compared with respect to their content of nonspecific hyaluronidase inhibitor and mucoprotein. Elevations in serum levels of hyaluronidase inhibitor and mucoprotein were found in maternal serum while decreased concentrations of mucoprotein and normal levels of hyaluronidase inhibitor characterized the serum of infants at birth. Mucoprotein concentrations in maternal serum increase for a period following delivery and remain at high levels for at least one month. Increase from low mucoprotein levels occurred in infants' serums during the first month of life and levels comparable to those of normal adults were found throughout the remainder of the first year. The relation of these findings to studies of other protein constituents in maternal and infant serum is discussed as are possible mechanisms to explain the results obtained.
PUBLIC HEALTH, NURSING AND MEDICAL SOCIAL WORK
Authors: TURNBLADH WILL C.
Published: December 2021

INCREASINGLY, in recent years, pediatricians have been called on to work with the problem of juvenile delinquency. Published statistics on crimes and antisocial activities by children have sometimes been frightening, and loose remarks are often made about drastic remedies being needed to "curb" modern youth. In such a situation, parents naturally turn to their physicians for advice and counsel.

Within the community pattern of the attack on juvenile delinquency, the "juvenile court" has a central role. If the ignorance of this editor is any index, pediatricians, in general, know little of the structure, responsibilities, jurisdiction, community relationships, and standards of juvenile courts. It is, for example, both revealing and reassuring to learn that ". . . the court stands in the position of a `protecting parent' rather than a prosecutor. . . ."

The National Probation and Parole Association, a nonprofit citizen and professional organization with professional and technical staff, seeks to extend and improve probation and parole services for both children and adults throughout the country, to promote juvenile and domestic relations courts and to develop specialized facilities and programs for the detention of children. At the request of the editor, Mr. Will C. Turnbladh, Executive Director of the Association, has prepared the following interesting and informative article on the background and some of the problems of juvenile courts.
PYRIDOXINE DEPENDENCY: REPORT OF A CASE OF INTRACTABLE CONVULSIONS IN AN INFANT CONTROLLED BY PYRIDOXINE
Authors: HUNT ANDREW D. , STOKES JOSEPH , MCCRORY WALLACE W. , STROUD H. H.
Published: December 2021

A case of convulsions in an infant requiring pyridoxine for their control has been described. On oral dosage of pyridoxine 2 mg./day, seizures have now been controlled for 21 months, with no increase in dosage being required. A continuing need for pyridoxine is demonstrated by the recent reappearance of seizures following a short lapse of pyridoxine administration.

In the absence of biochemical evidence of pyridoxine deficiency, as measured by xanthurenic acid excretion following a tryptophane load, and with meager clinical evidence for the complete picture of such deficiency, the authors prefer to designate this phenomenon "pyridoxine dependency" The hypothesis has been propounded that this infant suffers a metabolic anomaly in pyridoxine metabolism resulting in convulsions in the absence of regular dietary pyridoxine supplements.
EVALUATION OF THE SKELETAL AGE METHOD OF ESTIMATING CHILDREN'S DEVELOPMENT
Authors: MAINLAND DONALD
Published: December 2021

An observer's variable error in skeletal age assessment of hand RGs (i.e., the irregular ion between independent readings of the same film) was studied on 1,124 readings of 326 films from 233 children aged 16 months to 17 years. seventy-nine of the RGs were full-size reproductions in Macyr's Nutrition and Chemical Growth in Childhood; the remainder were actual films of children in Halifax, Canada (healthy Orphanage residents and children examined in a nutrition survey).

There was no significant difference in variable error associated with the atlas (Todd, Greulich-Pyle), age of child, sex, differences between skeletal and chronologic age, differences between children, or differences between RGs of the same child, except for a tendency in the Macy Series for the poorest reproductions to have a larger variable error than the best reproductions. ions. In most readings the individual indicators were assessed separately and the results averaged, but a quicker method (over-all appraisal) did not produce a significantly different variable error. The quick method may be useful in large surveys, although it appears too coarse for the study of individual children.

The observer's variable error was expressed by standard deviations of approximately three months (Macy Series—both atlases; Nutritirn Series—Greulich-Pyle atlas) and four months (Orphanage Series—both atlases). With a standard deviation of three months an assessor must affix an error of ± 8.3 months to his estimate of a child's progress in skeletal age, in order to obtain confidence limits with 95% probability. If his standard deviation is four months he must allow ± 11.1 months. For evaluation of the assessment method, many observers' estimates of variable error are needed, and an appeal for data is issued.

After more than 1200 readings had been made the observer's practice lapsed for about a year. Reassessment of a random sample of RGs then showed, besides variable error, a mean systematic difference of approximately three months from the previous readings of the same films with the same atlas. To avoid this risk, any two films that are to be assessed for skeletal progress should be read within a few weeks of each other, and special precautions are therefore necessary to secure independence of the two readings.
FAMILIAL CONSTITUTIONAL PRECOCIOUS PUBERTY IN A BOY THREE YEARS OF AGE
Authors: MORTIMER EDWARD A.
Published: December 2021

A case of familial constitutional precocious puberty in a boy of 3 years is reported with a brief review of the nine previously described families. In addition, an eleventh instance is mentioned.
CONGENITAL HYPOPLASTIC ANEMIA
Authors: BURGERT E. OMER , KENNEDY ROGER L. J. , PEASE GERTRUDE L.
Published: December 2021

Peripheral blood values and the results of bone marrow studies in 12 children suffering from congenital hypoplastic anemia are presented. In these cases the erythrocyte counts were more than 1,000,000 cells below normal, the values for hemoglobin were more than 1 gm. below normal, and the total leukocyte counts were within the range of normal except in two cases. The differential leukocyte counts showed lymphocytosis (50 to 90.5%). The mean percentage for reticulocytes was 0.3, and the platelet counts ranged from 71,000 to 409,000, except in two instances.

Studies of bone marrow concentrations in six children showed a decreased myeloiderythroid layer. In 10 children differential counts of 1,000 nucleated cells in the marrow showed decrease of the percentages for normoblasts, with a range from 1.2 to 13.8 and a mean of 3.7. Myelopoiesis was fairly active, percentages for myeloid cells ranging from 32.5 to 63.4 with a mean of 46.4. The percentages for lymphocytes were increased with a range from 30.6 to 63.6 and a mean of 48.5. Maturation of the normoblasts blasts was arrested at the polychromatic stage. The myeloid-erythroid ratio was greatly increased, with a range from 4:1 to 43:1 and a mean of 19:1.

In the 12 children of this series the onset was before 15 months of age. There was a familial incidence of the disease in three cases. The anemia recurred every 3 to 8 weeks as long as the hypoplasia persisted, and transfusions provided the only means of controlling the anemic state. Nevertheless, most of these children grew, developed normally, and carried on normal activities. Sponstaneous remissions occurred in five. The duration of these remissions at the time of the last reports ranged from 20 months to approximately 8 years.
OBSTRUCTIVE JAUNDICE IN INFANTS WITH NORMAL BILIARY TREE
Authors: HARRIS RUTH C. , ANDERSEN DOROTHY H. , DAY RICHARD L.
Published: December 2021

Of 50 infants with persistent signs of biliary obstruction, not atresia, seen in the past 7 years, 16 had preceding hemolytic disease from ABO or Rh-incompatibility and 3 had acquired hemolytic anemia. One infant had probable serum hepatitis and 30 others had hepatitis of unknown etiology. All had a patent external biliary tract.

Clinically these patients had jaundice, light stools and dark urine. All appeared in a good state of nutrition except those with hepatitis of unknown cause. The results of laboratory studies have been similar in these patients and have included a high direct serum bilirubin, usually negative cephalin flocculation, frequently elevated zinc sulfate turbidity and low cholesterol esters. The urine urobilin may be absent or increased in amount.

Histologic studies of liver have shown the presence of multinucleated giant liver cells, much myelopoiesis and erythropoiesis, plugging of bile canaliculi and mild bile duct proliferation. Large amounts of yellow pigment have been found within the liver cells but this pigment has not taken the usual iron stains. Livers from patients with hepatitis of unknown etiology have shown more evidence of inflammation, cell necrosis and portal fibrosis than the others.

Pertinent laboratory studies to help differentiate these cases from biliary atresia have included determinations of serum bilirubin, zinc sulfate turbidity, cholesterol and cholesterol esters and urine urobilin. Studies of maternal and infant blood factors and search for evidence of agglutination and increased production of erythrocytes are also important. Tests not found to be useful in differentiation are cholesterol esterase, alkaline phosphatase and prothrombin time.

If diagnosis is impossible from clinical and laboratory information, exploration of the biliary tract with liver biopsy and diodrast cholangiography may be necessary. This procedure should be delayed until an adequate period of observation has elapsed and until the infant is over 4 months of age. Such a delay may result in spontaneous clearing of the jaundice with complete recovery.
PATENT DUCTUS ARTERIOSUS IN INFANCY
Authors: LYON ROBERT A. , KAPLAN SAMUEL
Published: December 2021

Patent ductus arteriosus produces symptoms in infancy which vary widely in kind and severity. Five patients observed during the past five years have been described briefly to illustrate these variations. One infant died at the age of one month with an aneurysm of the ductus. Another patient, with atypical signs, had a sevede degree of congestive failure until surgical treatment provided dramatic relief. In the other patients symptoms were limited to retardation of growth, frequent respiratory infections and atypical murmurs until the later months of infancy.

In spite of the variation of physical signs and of the radiologic and electrocardiographic findings, an accurate diagnosis can often be made early in life. When doubt exists, and especially in infants suffering from cardiac failure, cardiac catheterization, aortography or angiocardiography must be employed to secure information necessary for immediate surgical treatment.

Emphasis is placed upon the fact that patent ductus can be the sole lesion causing congestive failure in infancy.
VENTRICULAR SEPTAL DEFECT IN INFANCY
Authors: ENGLE MARY ALLEN
Published: December 2021

The clinical features and postmortem findings have been analyzed in nine infants who had a ventricular septal defect and died in heart failure. Possible explanations for the severity of the manifestations of this simple and common defect were considered. The differential diagnosis from other conditions associated during infancy with cardiac enlargement and pulmonary congestion was discussed. It is hoped that an awareness of the serious consequences of this malformation in certain patients and the ability to diagnose it accurately will be forerunners of successful surgery to correct the defect.
RESECTION OF ESOPHAGEAL VARICES
Authors: ECHEVERRÍA EDUARDO
Published: December 2021

Brief considerations are made on incidence, symptomatology, endoscopic and radiologic diagnosis of esophageal varices. Mention is made of various treatments advocated. Three cases in children are described; two of them complained of liver cirrhosis and one of blocking of portal vein and chronic congestive splenomegaly; all had profuse hematemesis by varices. Splenectomy and splenorenal anastomosis were practiced without results in two cases. In view of the persistence of hematemesis, an ample thoracotomy was performed, followed by longitudinal incision of the esophagus; this brought into view the varicous columns which were then resected. The esophagus was sutured in two layers. The postoperative course was satisfactory and the esophagoscopic control done two years afterwards in two of the cases showed there has been no reproduction of varices. The third case is still under observation.
RESUSCITATION OF THE NEWBORN INFANT
Authors: CHERNIACK R. M. , BOYD A.
Published: December 2021

IN ORDER to initiate respiration, the newborn infant must be able to overcome a resistance to expansion of the lungs which is often as high as 30 cm. H2O. The lungs will remain atelectatic until an adequate respiratory effort is made. The infant may make one or two feeble attempts at respiration but then cease breathing, perhaps because these efforts are of insufficient magnitude to overcome the atelectasis. In such instances the force of the respiratory movements may be increased by external stimuli while intubation and removal of secretions from the tracheo-bronchial tree may reduce the resistance to expansion so that the infant's efforts are adequate. However, certain infants appear to require additional assistance in order to overcome this resistance. If the presence of initial atelectasis is a significant factor in preventing the onset of respiration, it would seem reasonable to make a strong effort to alleviate this condition.

Since the lungs offer a resistance to expansion of about 30 cm. H2O, any resuscitating device should exert pressures great enough to overcome this resistance. However, Wilson, Torrey and Johnson found that while a pressure of 24.4 cm. H2O did not cause expansion of the lung of the stillborn infant, it was great enough to cause gross pulmonary damage. Others have warned of alveolar rupture at even lower pressures and for this reason present-day resuscitators operate at low pressures.

Day et al. have recently pointed out the importance of time-pressure relationships in overcoming atelectasis and demonstrated that a pressure of 40 cm. H2O effectively overcame atelectasis of animal foetal lungs without producing lung damage if the pressure was applied for less than 0.25 seconds. It was therefore of interest to develop a resuscitator operating on a "timed-pressure" principle and to study the results obtained when it was used in the resuscitation of newborn infants with markedly depressed respiration.
EFFECT OF HIGH CONCENTRATIONS OF CARBON DIOXIDE AND OXYGEN ON THE RESPIRATION OF FULLTERM INFANTS
Authors: MILLER HERBERT C.
Published: December 2021

Five percent carbon dioxide added to 20% oxygen is a more powerful stimulus to respiration of healthy fullterm infants than is 100% oxygen. Fullterm infants hypoventilating as a result of exposure to low concentrations of oxygen had their minute volumes restored more rapidly and to a greater extent when 5% carbon dioxide was added to oxygen concentrations varying from 12 to 95% than when 100% oxygen was administered.

The age of the infant appeared to have but slight effect on the response made to breathing 5% carbon dioxide or 100% oxygen. Infants under two or three hours of age were not tested.

The value of adding carbon dioxide to air or oxygen in the treatment of "asphyxia neonatorum" has been discussed. Too little is known concerning the chemical, physiologic and anatomic changes occurring in this loosely termed condition or even in healthy newborn infants to warrant a pessimistic attitude towards the use of 5% carbon dioxide added to air or oxygen in the treatment of newborn infants with respiratory insufficiency.
MECHANISMS OF ACTION OF VITAMIN D
Authors: HARRISON HAROLD E.
Published: December 2021

EVER since the custom was inaugurated so brilliantly by Ashley Weech, the President of this society has been given the privilege of opening the meeting with a summary of some phase of his own research interests and since his paper is not open to discussion from the floor he can theorize a bit without the restraint of possible quick rebuttal. I have chosen to discuss the work on the "Physiology of Vitamin D" in which my wife and I have been engaged for a number of years. Since we have been in Baltimore we have been fortunate in having the benefit of Dr. Park's ideas and assistance, and the inspiration of his active interest in these studies.

Research activity in this field abruptly diminished when the practical applications of the discovery of vitamin D resulted in the virtual disappearance of rickets as a clinical problem. Many of the physiological problems remain unsolved, however, and our interest has been focused on the mechanism of action of the various sterols with vitamin D activity. In the following discussion many important contributions to this problem are omitted because of limitation of time.

We might first clarify certain quantitative aspects of vitamin D dosage. Figure 1 shows the Wide range of dosage over which vitamin D has been used in patients. A dose of 10 micrograms per day is adequate for the prevention of rickets in the normal infant whereas one to five milligrams per day or more have been required in the maintenance of patients with refractory rickets and hypoparathyroidism. It would seem possible that different biochemical systems might be involved at these extremes of dosage.
NITROGEN BALANCES ON LOW NITROGEN INTAKES IN INFANTS AND THE EFFECTS OF GELATIN SUPPLEMENTATION WITH AND WITHOUT VITAMIN B12 AND AUREOMYCIN
Authors: KAYE ROBERT , CAUGHEY RONALD H. , MCCRORY WALLACE W.
Published: December 2021

1. A group of five male infants who received an average nitrogen intake of 98 mgm./kg./day, derived from cow's milk protein, retained an average of -2.0 mgm./ kg./day. Small positive balances were achieved at intakes of 110 mgm./kg./day in two subjects. An intake of 100 mgm./kg./ day in two subjects resulted in one instance of nitrogen equilibrium and one of negative nitrogen balance. In the subject given the lowest nitrogen intake, 70 mgm./kg./day a negative nitrogen balance was encountered. These data suggest that the lower limit of nitrogen intake for equilibrium in infants under the experimental conditions reported here is approximately 110 mgm./kg./day.

2. Two of these subjects received gelatin supplements providing 120 mgm. N/ kg./day, and responded with increased nitrogen retentions of 50 and 60 mgm. N/ kg./day.

3. Retention of the gelatin supplements was not further increased in either subject by the administration of 300 µg. of vitamin B12, and 200-300 mgm. of aureomycin daily.

4. The provision of a protein which does not contain all of the essential amino acids, as a supplement to protein of good biological quality permits real augmentation of nitrogen retention.

5. Certain implications of the data in regard to the nutritional value of sub-optimal intakes of nitrogen and total calories have been discussed.
ABNORMALITIES OBSERVED DURING THE FIRST SIX DAYS OF LIFE IN 8,716 LIVE-BORN INFANTS
Authors: HARRIS LLOYD E. , STEINBERG ARTHUR G.
Published: December 2021

This is a report of the abnormalities, both congenital and acquired, observed during the first six days of life in 8,716 live-born infants. Postmortem findings are not included. The difficulties encountered in reporting and comparing the incidence and frequencies of abnormalities are discussed, the method of gathering the data is described and terms are defined when necessary. The abnormalities are presented according to systems, namely gastrointestinal, respiratory, nervous, genitourinary, skeletomuscular, blood and cardiovascular, and skin.
LONGITUDINAL STUDY OF THE INCIDENCE OF CENTRAL NERVOUS SYSTEM DAMAGE FOLLOWING ERYTHROBLASTOSIS FETALIS
Authors: JONES MARGARET H. , SANDS RUSSELL , HYMAN CAROL B. , STURGEON PHILLIP , KOCH FREMONT P.
Published: December 2021

One hundred unselected cases of erythroblastosis fetalis treated at Childrens Hospital in the newborn period have been followed from six months to five years in an effort to evaluate the relation of central nervous system signs in the newborn period to neuromuscular handicap and overall development later.

Of those showing no central nervous system signs in the newborn period 4% showed definite abnormality later.

Of those showing equivocal signs in the newborn period 33% showed definite abnormality later.

Of those having definite signs early, 100% continued to show abnormality in infancy and childhood.

There was no relation of the severity of the signs in the newborn period to the severity of the later handicap.

It is suggested, therefore, that one cannot be certain of the later normality of an infant showing no definite or equivocal central nervous system involvement in the newborn period. Careful following of all erythroblastotic infants until six to eight years of age or longer is advisable.
NUVARONES® IN THE TREATMENT OF CONVULSIVE DISORDERS (CLINICAL NOTE)
Authors: PETERMAN M. G.
Published: December 2021

FOR the past six years a new hydantoinate, 3-methyl 5-phenylhydantoin. Nuvarone®, has been tried in selected cases of convulsive disorders. A preliminary report was made in 1952. This compound was being investigated simultaneously by others and two reports have appeared. The latter concerned 130 patients, 91 of whom were treated for one to 24 months. The results were reported as "good" in 44 and "fair" in 38 patients. The side effects were noted as "mild and transitory."

In the present series 72 patients under 16 years of age were treated for six months to six years. In nine patients Nuvarone® was the initial drug in treatment. In 38 patients Nuvarone® was gradually substituted for other compounds which had been inadequate. Nuvarone® was used in conjunction with other preparations such as phenobarbital or Gemonil® in 34 patients. It should not be used with other hydantoin compounds, Phenurone®, or the diones.

Complete blood counts, complete urinalyses (including urobilinogen tests), sedimentation rates, and electroencephalograms were done on all patients before and after Nuvarone® was started. The blood counts and urinalyses were repeated in two weeks and monthly thereafter with platelet counts in addition. Ieterus index and sedimentation rate were obtained every one to three months. No abnormal changes were noted. Two patients developed leucopenia but none developed thrombocytopenia. One patient had an allergic sensitivity to Nuvarone® and developed a generalized maculopapular erythema with leucopenia each of the three occasions the drug was instituted. Another developed leucopenia (to 3,200 w.b.c.) with no other blood changes and although the drug has been continued three years the leucocyte count has gradually increased to 7,500.
TREATMENT OF HEMANGIOMA OF THE SKIN IN INFANCY AND CHILDHOOD BY ROENTGEN IRRADIATION AND RADIUM
Authors: ABDULKERIM ANIS , BOYD JOSEPH A. , REEVES ROBERT J.
Published: December 2021

A group of 323 cases of hemangioma of the skin were studied and follow-up results are given. The majority were of the cavernous and strawberry types. The classifications given are according to the relative sensitivity to irradiation. Various groups are separated depending on the type of treatment used.

The sites of predilection are the head and face. Complications are not frequent if treatment is given carefully.
SPECIAL ARTICLE
Authors:   THE EXAMINATIONS COMMITTEE
Published: December 2021

THE WRITTEN examination of January 15, 1954, was taken by 515 candidates, a larger number than in any previous year except 1953 when there were 607 candidates Grades ranged from a lowest mark of 32.0 to a highest mark of 89.5 Inspection of the range resulted in the decision to place the passing mark at 51. On this basis there were 32, or 6.2%, who failed and were therefore ineligible for oral examination.

The distribution of the grades earned by the 515 candidates is presented in the form of a histogram. As an aid to visual assessment of the nature of the distribution, a normal frequency curve computed from the mean and standard deviation of the data has been superimposed on the diagram. The distribution of the grades is clearly and impressively skewed to the left, that is, the scores tend to be massed at the high end of the scale and spread out at the low end. An examination of this type is relatively sensitive in the zone of poorer scholarship where the selection of failures is to be made and relatively insensitive in the range of higher scholarship.

The intrinsic reliability of the examination has again been assessed by comparing the grade made by each candidate on his odd-numbered questions with that earned on his even-numbered questions. The comparison reveals a "probable error of estimate," P.E.m, of 2.39, a lower figure and therefore a higher degree of reliability than yielded by any previous examination. The Committee is pleased that the increase in reliability was accomplished in spite of the fact that the length of the examination was decreased from 250 grading points in 1953 to 200 grading points.
CERTAIN ASPECTS OF THE RENAL REGULATION OF BODY COMPOSITION
Authors: COOKE ROBERT E.
Published: December 2021

THE pH of extracellular fluid is determined by the ratio of the plasma concentrations of bicarbonate ion to carbonic acid, as given in the classical Henderson-Hasselbach equation. [See Equation in Source Pdf] The denominator the carbonic acid concentration, [H2CO3], is proportional to the carbon dioxide tension of the blood. The carbon dioxide tension (pCO2) is primarily dependent upon respiratory function, since metabolism (hence carbon dioxide production) is relatively constant.

The numerator of the equation—the bicarbonate concentration of extracellular fluid—is determined by the difference between nonvolatile cations and anions. Since there are almost limitless quantities of bicarbonate available to the organism from cell metabolism, [See Equation in Source Pdf] bicarbonate concentration must change whenever nonvolatile cation (largely sodium) is altered in relation to nonvolatile anion (largely chloride). Thus in most states extracellular bicarbonate concentration is dependent upon the ratio of sodium to chloride in extracellular fluid.

The quantity of water filtered at the glomeruli and reabsorbed by the renal tubules each day is approximately 15 times the extracellular volume. The quantity of sodium chloride filtered and reabsorbed daily is approximately 15 times that contained in the extracellular space and 150 times that usually ingested and excreted each day. Therefore, the ratio of plasma sodium to chloride in any steady state is determined by the composition of the renal tubular reabsorbate, as Cushny pointed over 30 years ago. In a sense the kidney perfuses the extracellular space with large quantities of tubular reabsorbate. Tubular reasorbate—the net quantity of materials reabsorbed by the tubules. This term is analogous to glomerular filtrate—the quantity of materials filtered by the glomeruli.
ANTIBODY RESPONSES TO NATURALLY OCCURRING POLIOMYELITIS INFECTIONS IN CHILDREN
Authors: MILLER C. ARDEN , WENNER HERBERT A.
Published: December 2021

Thirteen of fourteen children with a clinical diagnosis of poliomyelitis showed high neutralizing antibody titers in tissue culture tests aganst prototype viruses, as early as two days after the first symptom, and persisting for as long as 18 months without significant change in titer. A significant increase in titer from that during the first week was occasionally encountered, but the initial titer was usually in the same range as that of the subsequent 18 months. The 14th child had antibodies against none of the prototype poliomyelitis viruses, though his clinical history was quite compatible with a non-paralytic infection. In the third month this patient's Type 2 antibody rose after six negative serums to 1:5120, possibly indicating an inapparent poliomyelitis infection several months after an erroneous diagnosis of poliomyelitis.

Stool specimens were available from seven of the 14 children. Six Type 1 poliomyelitis viruses and one Type 2 virus were recovered from these stools. Neutralizing antibody titers against the patient's own virus closely paralled those against the homologous prototype virus. When differences did occur, they were in favor of higher antibody titers against the patient's own virus.

Serums from 10 patients had antibodies against more than one prototype virus. With the exception of only two patients, antibodies against one of the prototype viruses were present far in excess of the others. Possible explanations for the heterotypic antibodies are discussed.

Neutralization tests, as performed, appear to be of value in ruling out a diagnosis of poliomyelitis, but not in establishing the diagnosis.
A TECHNIQUE FOR ROENTGENOGRAPHIC EXAMINATION OF NEWBORN, PREMATURE, OR ILL INFANTS WITHOUT REMOVAL FROM AN INCUBATOR
Authors: SILVER HENRY K. , NYHAN WILLIAM L.
Published: December 2021

THE NECESSITY for roentgenographic examination as an adjunct to diagnosis and therapy during the neonatal period is well recognized. The indications for such examination and some of the difficulties encountered in its use are well known. The undesirable aspects of excessive handling of ill or delicate infants or of removing them from a source of constant oxygen, heat, and humidity may preclude examination when it is most needed. Certainly the hurry imposed by these difficulties often militates against satisfactory examination.

A technique is described which permits adequate roentgenographic evaluation without disturbance to the infant, cessation of oxygen therapy, or alteration of environmental temperature or humidity.
SMALL CELL CARCINOMA OF THE THYROID GLAND OF YOUTH
Authors: Buckwalter Joseph A. , Meredith L. K.
Published: December 2021

The literature concerned with round cell carcinoma which occurs in youth has been reviewed. One case has been described in which rapid progress of the lesion occurred in spite of surgical and irradiation therapy. It is suggested that maximal doses of external irradiation be used to supplement surgical extirpation.
RAT MITE DERMATITIS IN CHILDREN
Authors: Haggard Carl N.
Published: December 2021

DERMATITIS due to a specific etiologic agent, which responds immediately to therapy, is rather exceptional among eruptions in infancy.

Exploratory activities of toddlers often lead them to habitats and runways of rodents. Time belief that acariasis acquired by this direct manner may commonly be overlooked suggested that the present observations should be recorded.

CASE REPORT

A foundling home was being razed to make room for a new modern building. As portions of the house were torn down, occupants were moved to intact parts of the building. As the building proceeded, the need for rat extermination became increasingly great. About this time, adult occupants complained of itching rashes, and these failed to respond to a variety of common remedies.
REVIEW ARTICLE
Authors: Dawson Jean P.
Published: December 2021

1) A case of hypoplastic anemia with multiple congenital anomalies (Fanconi's type) is reported. The patient exhibited pancytopenia associated with skin pigmentation, small stature and anomalies of the skeletal and genito-urinary systems.

2) The literature is reviewed and the characteristics of the disease discussed.

3) Management and therapy are discussed.
SPECIAL ARTICLE
Authors: Samuels Sidney S.
Published: December 2021

THE DIAGNOSIS of non-suppurative, secretory otitis media has been made much more frequently in recent years than it was prior to 1950. This increase has been noticed in children many more times than in adults, as pointed out by Robison and Nicholas. The disease is much more commonly found because of increased vigilance some otologists believe, as does Suehs, since the entity was reviewed and clarified by the brilliant work of Hoople in that year.

However, there are undoubtedly other factors contributing to the greater incidence of this entity, such as the increased use of antibiotics in upper respiratory infections, including otitis media; an increase in the number of so-called virus infections; the greater prevalence of allergic diathesis; increased air travel; and, as Lindsay states, the swing of time pendulum toward extreme conservatism in recommending removal of tonsils and adenoids, a tendency resulting partly from a sense of security afforded by antibiotic therapy.

The condition has received more of the attention it merits lately from that group of practitioners who are first in contact with the patients, namely the pediatrician and general practitioner who attend the acutely ill child. For usually the actual onset of the illness is acute, an otitis media occurring during an acute upper respiratory infection or as an acute otitis media following such an illness. The former need not even reach the stage where it is definitely recognized, its progress being halted by the antibiotic treatment administered.

The attention of the attending physiciain is focused upon the middle ear in the younger child, either by the presence of pain in the affected ear, or by the abnormal appearance of the tympanic membrane, or both.
A COMPARISON OF ORAL BENZATHINE PENICILLIN G AND SULFONAMIDES FOR THE PREVENTION OF STREPTOCOCCAL INFECTIONS AND RECURRENCES OF RHEUMATIC FEVER
Authors: Markowitz Milton , Hemphill Woodrow
Published: December 2021

1. The incidence of recurrences of rheumatic fever and streptococcal infections in 82 rheumatic subjects receiving a 200,000 unit tablet of benzathine penicillin G daily was compared with that in 64 rheumatic patients on a standard daily dose of a triple sulfonamide preparation, while both groups were followed for an average period of 13 months.

2. A total of 9 recurrences of rheumatic fever was noted, 4 in the group treated with penicillin and 5 among patients on sulfonamides.

3. The incidence of streptococcal infections as determined by a significant rise in the antistreptolysin O titer was essentially the same in both groups. Group A streptococci were found in the throat in about the same number of patients in each group.

4. Toxic reactions of a mild nature were noted in 7 patients (11 per cent) receiving sulfonamides as compared to 2 patients (2.5 per cent) on oral penicillin.

5. A single daily dose of 200,000 units of benzathine penicillin G is as effective a prophylactic agent as the sulfonamides for the prevention of rheumatic fever. Its chief advantage is the lower incidence of toxic reactions.
CONCENTRATION IN PLASMA AND RATE OF URINARY EXCRETION OF AMINO ACIDS IN PREMATURE INFANTS
Authors: Sereni Fabio , McNamara Helen , Shibuya Madoka , Kretchmer Norman , Barnett Henry L.
Published: December 2021

Clearances of total and individual amino acids and of endogenous creatinine were measured in 2 groups of premature infants (less than 17 and more than 27 days of age), in full-term infants, children and adults. The results indicate that:

1) the concentration of total amino acids in plasma is higher in the premature infant; in the younger premature infant this higher concentration is due principally to higher concentrations of glycine, serine, threonine, glutamine, tyrosine and phenylalanine;

2) the clearances and rates of excretion of total amino acids and of most individual amino acids are higher in the older premature infants than in any other group of subjects; in the infants, but not in the children and adults, there appeared to be a direct relationship between rate of urine flow and rate of excretion of total amino acids, and

3) compared with the child and the adult, the higher rate of excretion of the amino acids in the older premature infant is due principally, not to the higher concentration in plasma, but to a lower rate of reabsorption of amino acids by the renal tubules. Although the rate of reabsorption of amino acids in the younger premature infant is also low, the very low rate of filtration results in a rate of excretion similar to that of the child and the adult.

It is concluded that, although a metabolic factor may be involved, the increased rate of excretion of amino acids in the older premature infant is due principally to a difference in the handling of amino acids by the kidney.
EDUCATION
Authors: Whittemore Ruth
Published: December 2021

In conclusion, the plans which have evolved during the conducting of 6 different meetings of mixed professions on the public health aspects of rheumatic fever and pediatric cardiology have been presented with the hope that, because of the benefits and better understanding derived, such experiences may be of some assistance to others and possibly stimulate other groups to hold conferences of a similar nature.