bluuebunny/crossref_metadata_2025 huggingface dataset:
Ultrasound Examination of Extensive Limb Swelling Reactions After Diphtheria-Tetanus-Acellular Pertussis or Reduced-Antigen Content Diphtheria-Tetanus-Acellular Pertussis Immunization in Preschool-Aged Children
Authors: Marshall Helen Siobhan , Gold Michael Steven , Gent Roger , Quinn Patrick John , Piotto Lino , Clarke Michelle Frances , Roberton Donal Muir
Published: October 2006

OBJECTIVE. The aim of this study was to determine the site, extent, and resolution of tissue involvement when extensive limb swelling occurred in the injected limb for children who received diphtheria-tetanus-acellular pertussis or reduced-antigen content diphtheria-tetanus-acellular pertussis vaccine at 4 to 6 years of age.

METHODS. Children who had experienced an injection site reaction at 18 months of age were assigned randomly to receive an intramuscular injection of either reduced-antigen content diphtheria-tetanus-acellular pertussis vaccine or diphtheria-tetanus-acellular pertussis vaccine between 4 and 6 years of age. Children who developed extensive limb swelling were recruited for assessment by clinical examination; ultrasound studies of the affected and opposite (control) arms were performed 24 to 48 hours after immunization and 48 to 96 hours later.

RESULTS. Twelve children with extensive limb swelling were enrolled in the study. Ultrasound examinations demonstrated swelling of both the subcutaneous and muscle layers of the vaccinated arm. Ultrasound assessment showed that the swelling exceeded the clinical measurements of skin redness and swelling. Subcutaneous and muscle tissues expanded to 281% and 111% of the tissue thicknesses of the control arm, respectively. Repeat ultrasound examinations after 48 to 96 hours showed considerable resolution of muscle swelling, compared with subcutaneous tissue swelling. There was no significant difference in the extent of swelling detected between children who received diphtheria-tetanus-acellular pertussis vaccine and those who received reduced-antigen content diphtheria-tetanus-acellular pertussis vaccine.

CONCLUSION. Extensive limb swelling reactions after diphtheria-tetanus-acellular pertussis or reduced-antigen content booster immunizations involved swelling of subcutaneous and muscle tissues with swelling and duration more marked in subcutaneous tissue.
Pediatric Precursors of Adult Cardiovascular Disease: Noninvasive Assessment of Early Vascular Changes in Children and Adolescents
Authors: Groner Judith A. , Joshi Mandar , Bauer John A.
Published: October 2006

BACKGROUND. Until recently, our understanding of the childhood antecedents of adult cardiovascular disease was limited mainly to autopsy studies and pathologic findings in teens and young adults who died from accidental causes. Recent advances in the understanding of atherosclerosis and new technologies allowing detection of early events have made it possible to observe anatomic and physiologic evidence of cardiovascular disease in young adults and children.

OBJECTIVES. The goal of this article was to introduce pediatricians to new methods for noninvasive measurement of cardiovascular disease and its precursors, to describe the potential application of these techniques in detecting childhood precursors of adult cardiovascular disease, and to summarize knowledge gained from this approach.

METHODS. We conducted a computerized search of peer-reviewed articles listed in PubMed and Medline from 1980 to April 2006. We reviewed 63 and 84 articles from the adult and pediatric literature, respectively.

RESULTS. Reviewing the research on childhood antecedents of adult cardiovascular disease is sobering. Vascular alterations in anatomy, physiology, mechanical properties, and proinflammatory and prothrombotic changes are present from a very early age of childhood and are associated with the risk factors common in adult cardiovascular disease. At the same time, this body of research supports the concept that the vascular impairment from childhood may improve over time with appropriate intervention.

CONCLUSIONS. The measurement tools and concepts described in this article offer diagnostic and therapeutic opportunities for collaboration between clinical pediatricians and pediatric researchers. These partnerships will enable pediatricians to contribute in an effort to reduce the burdens of cardiovascular disease to individuals, families, and society.
Bullying and Peer Victimization Among Children With Special Health Care Needs
Authors: Van Cleave Jeanne , Davis Matthew M.
Published: October 2006

BACKGROUND. Dr Van Cleave’s current address is Department of Pediatrics, Center for Child and Adolescent Health Policy, MassGeneral Hospital for Children, 50 Staniford St, Room 901, Boston, MA 02114. The association between bullying, being bullied, or being a bully/victim and having a special health care need has not been well described in a national sample of children with a broad variety of special needs.

OBJECTIVE. We aimed to determine the prevalence of bullying, being bullied, or being a bully/victim in children with special health care needs and associations of behaviors with particular types of special needs.

DESIGN. We performed a secondary data analysis using the National Survey of Children's Health, a nationally representative telephone survey conducted by the National Center for Health Statistics of >102000 US households.

METHODS. We measured associations between having a special health care need and being a victim of bullying, bullying other children, and being a bully/victim in children and adolescents aged 6 to 17 years. Multiple logistic-regression models were used to examine the association of children with special health care needs overall, and of particular special needs, with the bullying measures.

RESULTS. Overall, children with special health care needs were 21% of the population. In multivariate models adjusting for sociodemographic factors, being a child with special health care needs was associated with being bullied but not with bullying or being a bully/victim. Having a chronic behavioral, emotional, or developmental problem was associated with bullying others and with being a bully/victim.

CONCLUSIONS. Having a special health care need generally is associated with being bullied, and having a behavioral, emotional, or developmental problem is associated with bullying others and being a bully/victim. These findings may help pediatricians, mental health providers, and schools use targeted screening and interventions to address bullying for children with special health care needs.
Comparison of Outcome Measures for a Traditional Pediatric Faculty Service and Nonfaculty Hospitalist Services in a Community Teaching Hospital
Authors: Boyd John , Samaddar Kristen , Parra-Roide Lilia , Allen Edith Prieto , White Bruce
Published: October 2006

OBJECTIVE. Several studies have found decreased cost and length of stay for patients who are cared for by pediatric hospitalists compared with traditional faculty models. The objective of this study was to compare cost and length of stay between a faculty group and 2 separate hospitalist groups in a community teaching hospital. This study differs from previous ones in that both the traditional faculty and hospitalist models were in place simultaneously, and the traditional faculty group was employed by the hospital, whereas the hospitalist groups were in private practice.

METHODS. A total of 1009 pediatric patients with any of the 11 most frequent diagnosis-related groups were analyzed according to the admitting physician group. Total direct costs and length of stay were computed for 3 separate groups (faculty group, hospitalist group 1, and hospitalist group 2). Linear regression models were used to compare total direct costs and length of stay among the groups. Each model accounted for age, severity index, and payer source.

RESULTS. Age, severity index, and physician group were predictive in determining total direct costs and length of stay. There was no significant difference in patient age among the groups, but the faculty group had significantly increased severity indices compared with hospitalist groups 1 and 2 (1.6 ± 0.7 vs 1.3 ± 0.6 vs 1.4 ± 0.6, mean ± SD). The faculty group had statistically significantly lower total direct costs compared with hospitalist groups 1 and 2 ($1781 ± $1449 vs $1954 ± $1212 vs $1964 ± $1495, mean ± SD). The faculty group had shorter average length of stay compared with hospitalist groups 1 and 2 (2.6 ± 2.0 vs 3.1 ± 2.6 vs 2.9 ± 2.3, mean ± SD). The readmission rates among the groups were similar.

CONCLUSIONS. Traditional faculty models can be as efficient in terms of total direct costs and length of stay as evolving hospitalist models. This study's results may be unique because the traditional faculty model was composed of general pediatricians instead of a blend of generalists and subspecialists. In addition, the traditional faculty physicians concentrated almost entirely on the care of inpatients while engaged in hospital care.
Evaluation of Resident Communication Skills and Professionalism: A Matter of Perspective?
Authors: Brinkman William B. , Geraghty Sheela R. , Lanphear Bruce P. , Khoury Jane C. , Gonzalez del Rey Javier A. , DeWitt Thomas G. , Britto Maria T.
Published: October 2006

OBJECTIVE. Evaluation procedures that rely solely on attending physician ratings may not identify residents who display poor communication skills or unprofessional behavior. Inclusion of non-physician evaluators should capture a more complete account of resident competency. No published reports have examined the relationship between resident evaluations obtained from different sources in pediatric settings. The objective of this study was to determine whether parent and nurse ratings of specific resident behaviors significantly differ from those of attending physicians.

METHODS. Thirty-six pediatric residents were evaluated by parents, nurses, and attending physicians during their first year of training. For analysis, the percentage of responses in the highest response category was calculated for each resident on each item. Differences between attending physician ratings and those of parents and nurses were compared using the signed rank test.

RESULTS. Parent and attending physician ratings were similar on most items, but attending physicians indicated that they frequently were unable to observe the behaviors of interest. Nurses rated residents lower than did attending physicians on items that related to respecting staff (69% vs 97%), accepting suggestions (56% vs 82%), teamwork (63% vs 88%), being sensitive and empathetic (62% vs 85%), respecting confidentiality (73% vs 97%), demonstrating integrity (75% vs 92%), and demonstrating accountability (67% vs 83%). Nurse responses were higher than attending physicians on anticipating postdischarge needs (46% vs 25%) and effectively planning care (52% vs 33%).

CONCLUSIONS. Expanding resident evaluation procedures to include parents and nurses does enhance information that is gathered on resident communication skills and professionalism and may help to target specific behaviors for improvement. Additional research is needed to determine whether receiving feedback on parent and nurse evaluations will have a positive impact on resident competency.
The Impact of Public Insurance Expansions on Children’s Access and Use of Care
Authors: Duderstadt Karen G. , Hughes Dana C. , Soobader Mah-J , Newacheck Paul W.
Published: October 2006

OBJECTIVE. Our goal was to examine the impact of the State Children’s Health Insurance Program nationally on children’s access and use of health care.

OBJECTIVE. Our data source was the National Health Interview Survey, using 1997 as a baseline, which predates the implementation of the State Children’s Health Insurance Program, and 2003 as the end point of the analysis. We analyzed 25 734 children aged 0 to 18 years (1997 and 2003 combined) to examine changes in health insurance coverage rates, health care access, and utilization for children in the State Children’s Health Insurance Program target population, defined here as those living in families with incomes between 100% and 199% of the federal poverty level.

RESULTS. Children in the State Children’s Health Insurance Program target income group showed the largest reduction in rates of uninsurance among 3 income groups (<100%, 100%–199%, and ≥200% of the federal poverty level) between 1997 and 2003 (15.1%–8.7%). Significant reductions occurred in the proportion of children without a usual source of care in the target income group (9.4%–7.3%) and in the proportion of children without a provider visit in the past year (10.8%–9.8%). Other measures (unmet needs, delayed care, volume of provider visits, receipt of well-child care, and dental care) showed no significant changes over this time period. A separate multivariate analysis restricted to the State Children’s Health Insurance Program target population in 2003 showed that children with continuous public coverage had significantly better access and utilization on all measures studied when compared with uninsured children and performed as well or better than children with continuous private coverage.

CONCLUSIONS. Implementation of the State Children’s Health Insurance Program is associated with substantial gains in public coverage for children in the target income group. Although some of these gains were offset by losses in private coverage, our findings demonstrate that public health insurance provides significant benefits in terms of access and utilization for children living in the target income group.
Factors Associated With Establishing a Causal Diagnosis for Children With Cardiomyopathy
Authors: Cox Gerald F. , Sleeper Lynn A. , Lowe April M. , Towbin Jeffrey A. , Colan Steven D. , Orav E. John , Lurie Paul R. , Messere Jane E. , Wilkinson James D. , Lipshultz Steven E.
Published: October 2006

OBJECTIVE. The goal was to identify the clinical variables associated with establishing a cause of cardiomyopathy in children.

METHODS. The Pediatric Cardiomyopathy Registry contains clinical and causal testing information for 916 children who were diagnosed as having cardiomyopathy in North America between 1990 and 1995. Children with a causal diagnosis were compared with those without with respect to several demographic, clinical, and causal testing variables.

RESULTS. Cardiomyopathy was 1 of 4 types, hypertrophic (34.2%), dilated (53.8%), restrictive (3.2%), or other or mixed (8.9%). Only one third of cases had a known cause. Children with a known cause for hypertrophic cardiomyopathy were more likely to be female, to be relatively smaller, to present with congestive heart failure, and to have increased left ventricular posterior wall thickness without outflow tract obstruction. For dilated cardiomyopathy, a known cause was associated with older age, lower heart rate, smaller left ventricular dimensions, and greater shortening fraction. Family history of cardiomyopathy predicted a significantly higher rate of causal diagnoses for all cardiomyopathy types, whereas family histories of genetic syndromes and sudden death were also predictive of a cause for hypertrophic and dilated cardiomyopathies. For hypertrophic cardiomyopathy, only blood and urine testing was associated with a causal diagnosis, whereas both viral serologic testing or culture and endomyocardial biopsy were independent predictors of a causal diagnosis in dilated cardiomyopathy.

CONCLUSIONS. Certain patient characteristics, family history, echocardiographic findings, laboratory testing, and biopsy were associated significantly with establishing a cause of pediatric cardiomyopathy. Early endomyocardial biopsy should be considered strongly for children with dilated cardiomyopathy, for definitive diagnosis of viral myocarditis. Although not widely used, skeletal muscle biopsy may yield a cause for some patients with hypertrophic cardiomyopathy and for patients suspected of having a mitochondrial disorder.
Population-Based Study of the Impact of Childcare Attendance on Hospitalizations for Acute Respiratory Infections
Authors: Kamper-Jørgensen Mads , Wohlfahrt Jan , Simonsen Jacob , Grønbæk Morten , Benn Christine Stabell
Published: October 2006

OBJECTIVES. It is well known that children attending childcare have a higher risk of acute respiratory infections compared with children in home care; however, knowledge is sparse regarding how the excess risk of acute respiratory infection varies with age, time since enrollment, and other factors.

METHODS. A national register-based study of 138821 inpatient admissions to hospital for acute respiratory infection during 3982925 person-years of follow-up in Danish children aged 0 to 5 years. Data on child and family characteristics, childcare attendance, and hospitalizations were obtained from Danish registries. The outcome of the study was inpatient admissions to hospital for acute respiratory infection. Incidence rate ratios were estimated using Poisson regression.

RESULTS. In children <1 year of age, the first 6 months of enrollment in the first childcare facility were associated with a 69% higher incidence of hospitalizations for acute respiratory infection compared with children in home care. Similar figures for children aged 1, 2, and ≥3 years were 47%, 41%, and 8%, respectively. The incidence decreased after the first 6 months, and after ≥1 year in childcare the incidence was comparable with that of children in home care. Similar patterns were seen after second enrollment. For 0- to 2-year-old children living in households with no additional children <5 years, the excess incidence during the first 6 months of enrollment was 100% compared with 25% and 9% for children living with 1 and ≥2 additional children, respectively.

CONCLUSIONS. The increased risk of acute respiratory infection was most pronounced among 0- to 2-year-old children living with no other children during the first 6 months of enrollment. Our findings may suggest that it would be optimal to postpone enrollment into childcare until after 1 year of age.
Achieving Family and Provider Partnerships for Children With Special Health Care Needs
Authors: Denboba Diana , McPherson Merle G. , Kenney Mary Kay , Strickland Bonnie , Newacheck Paul W.
Published: October 2006

BACKGROUND. During the past 2 decades, family-centered care has evolved as the standard of care for children with special health care needs. A major principle of family-centered care is a strong partnership between the family and provider, working together to address issues and barriers to accessing comprehensive care and related services. The federal Maternal and Child Health Bureau defines a positive family-provider partnership as a core program outcome. Our objective was to assess the extent to which families of children with special health care needs feel as though they are treated as partners in decision-making by their doctors.

METHODS. We analyzed the 2001 National Survey of Children With Special Health Care Needs, a nationally representative telephone survey of caretakers for 38866 children with special health care needs. Bivariate and multivariate statistical methods were used to assess the frequency of meeting the partnership core outcome, as well as the demographic and socioeconomic predictors of meeting core outcome. We also examined the effect of partnership on indicators of access and well-being for children with special health care needs.

RESULTS. Among children with special health care needs, 85.8% of families reported usually or always feeling like a partner in their child's care. However, living in poverty, minority racial and ethnic status, absence of health insurance, and depressed functional ability placed children with special health care needs and their families at elevated risk of being without a sense of partnership. We found that sense of partnership was associated with improved outcomes across a number of important health care measures, including missed school days, access to specialty care, satisfaction with care, and unmet needs for child and family services.

CONCLUSIONS. Results of the survey demonstrated that whereas most families of children with special health care needs feel they are partners in the care of their child, further work is needed, particularly for poor, uninsured, and minority children, as well as those with functional limitations. The survey results also demonstrate the importance of partnership; children whose care met the partnership core outcome experienced improved access to care and well-being.
Incorporating Vaccine-Preventable Disease Surveillance Into the National Health Information Network: Leveraging Children's Hospitals
Authors: Fine Andrew M. , Goldmann Donald A. , Forbes Peter W. , Harris Sion K. , Mandl Kenneth D.
Published: October 2006

OBJECTIVE. Development of national biosurveillance systems to advance regional and national data exchange among sites of clinical care and public health authorities is a top federal priority, creating the opportunity to develop a unified national network for tracking and responding to cases of vaccine-preventable diseases. The purpose of this study was to assess the current practice and feasibility of developing a nationwide network of children's hospitals to conduct surveillance for vaccine preventable diseases.

METHODS. In 2004–2005, Web-based surveys were sent to 506 key hospital personnel from 119 pediatric hospitals, identified by the National Association of Children's Hospitals and Related Institutions. Surveys measured attitudes toward public health initiatives, willingness to join a surveillance network of children's hospitals, knowledge of mandated reporting requirements, methods of disease detection and reporting, and data sources available for surveillance.

RESULTS. A total of 395 (78%) respondents from 119 hospitals completed the survey. Surveillance at pediatric hospitals is largely passive and driven by unreimbursed efforts of infection control staff. It is vulnerable to missing cases that occur in the outpatient setting and are diagnosed clinically without laboratory confirmation or are never diagnosed by clinicians. Nearly 90% of hospital leaders are interested in participating in public health programs, and most are interested in a national network to conduct active surveillance for vaccine-preventable diseases, dependent on the provision of sufficient funding. Pediatric hospitals store records relevant to surveillance in an electronic fashion accessible to query, but <20% of these hospitals use automated methods to report cases of disease.

CONCLUSIONS. There is both the will and capability to create a robust active pediatric hospital-based reporting system for vaccine preventable diseases. This effort would dovetail well with the national priority to bolster surveillance, as well as with the goal of reducing morbidity and mortality from vaccine-preventable diseases.
Drowning in a Sea of Advice: Pediatricians and American Academy of Pediatrics Policy Statements
Authors: Belamarich Peter F. , Gandica Rachelle , Stein Ruth E. K. , Racine Andrew D.
Published: October 2006

OBJECTIVE. The proliferation of policy statements from the American Academy of Pediatrics presents pediatricians with an increasing amount of health advice to deliver, yet no quantitative estimates of pediatric health advice expectations exist in the literature. The objective of this study was to quantify and characterize verbal health advice that pediatricians are expected to deliver to patients/guardians.

METHODS. The authors read and coded the 344 American Academy of Pediatrics policy statements that are contained in the American Academy of Pediatrics' Pediatric Clinical Practice Guidelines and Policies, Third Edition, and identified 57 policies that contained health advice directives that are broadly relevant to pediatric practice. We extracted the individual advice text to a database in which we also coded its date of issue, its theme, and whether (1) it was duplicated in another policy, (2) a screening question was required to identify a target population for the advice, (3) handouts or other aids to delivering the advice were referenced in the policy itself, or (4) the text of the statement referred to evidence of the effectiveness of office-based delivery of the advice.

RESULTS. These 57 policies were found to contain 192 discrete health advice directives that pediatricians are expected to deliver to patients/guardians. Seven (4%) of these directives originated before 1993, and 185 (96%) were created from 1993 to 2002. After removal of the 30 (16%) duplicates, safety advice composed 67%, media use composed 12%, substance abuse composed 5%, environmental health hazards composed 4%, development/emotional health composed 4%, sexuality and pregnancy composed 3%, nutrition composed 2%, and miscellaneous composed 3%. In 41% of the directives, a screening question was required to identify the target population for the advice. Aids to delivering advice were referenced in 20% of the policies. In no policy statements did the text refer to evidence that office-based counseling was an effective method to achieve the desired health or behavioral outcome.

CONCLUSIONS. We examined the American Academy of Pediatrics policy statements and found 162 different verbal health advice directives on which pediatricians should counsel parents and patients throughout childhood. The expectation that delivery of all of this advice can be achieved is unrealistic. Moreover, none of the reviewed statements were found to include an evidence-based discussion of the efficacy of the suggested advice. In light of these findings, we suggest that committees should consider both the feasibility and the evidence of efficacy of office-based health advice when generating future policy statements.
Prolonged Rate-Corrected QT Interval and Other Electrocardiogram Abnormalities in Girls With Turner Syndrome
Authors: Bondy Carolyn A. , Ceniceros Irene , Van Phillip L. , Bakalov Vladimir K. , Rosing Douglas R.
Published: October 2006

BACKGROUND. We recently reported that electrocardiographic abnormalities are common in adults with monosomy X (Turner syndrome), but this issue has not been investigated in girls with Turner syndrome.

PATIENTS AND METHODS. We analyzed electrocardiograms in 78 girls with Turner syndrome and 50 age-matched control girls. The girls with Turner syndrome had additional cardiac and metabolic evaluations.

RESULTS. Girls with Turner syndrome were more likely to demonstrate ≥1 electrocardiographic findings including right axis deviation, right ventricular hypertrophy, accelerated atrioventricular conduction, T-wave abnormalities, and a prolonged rate-corrected QT interval. The right-sided findings were associated with partial anomalous pulmonary venous connection, but the etiology of the other findings remains unknown. The rate-corrected QT interval was significantly longer in girls with Turner syndrome (431 ± 22 vs 407 ± 21 milliseconds). Twenty-eight girls with Turner syndrome but only 2 controls had a rate-corrected QT interval above the reference range. We found no correlation between body habitus, cardiac dimensions, or metabolic parameters and the rate-corrected QT interval duration in girls with Turner syndrome.

CONCLUSIONS. Cardiac conduction and repolarization abnormalities seem to affect both young girls and adults with Turner syndrome equally, suggesting that electrophysiologic defects are intrinsic to the syndrome and indicating that electrocardiogram analysis should be included in evaluating and monitoring even the youngest patients with Turner syndrome. Attention to the rate-corrected QT interval is important, because some common medications may further prolong this interval and increase the risk of arrhythmias.
Emergency Medical Services System Changes Reduce Pediatric Epinephrine Dosing Errors in the Prehospital Setting
Authors: Kaji Amy H. , Gausche-Hill Marianne , Conrad Heather , Young Kelly D. , Koenig William J. , Dorsey Erin , Lewis Roger J.
Published: October 2006

OBJECTIVE. The goal was to describe the change in the rate of epinephrine dosing errors in the treatment of pediatric patients in prehospital cardiopulmonary arrest after the Los Angeles County Emergency Medical Services Agency instituted a program in which paramedics were required to use the Broselow tape and to report color zone categories to the base station and base stations were given and instructed formally in the use of the color-coded drug dosing chart.

METHODS. An observational analysis of a natural experiment was performed. Children ≤12 years of age who were determined to be in prehospital cardiopulmonary arrest and who received prehospital epinephrine treatment by paramedics, in the periods of 1994 to 1997 and 2003 to 2004, were included in the study.

RESULTS. In the 1994 to 1997 cohort, we identified 104 subjects in prehospital cardiopulmonary arrest who received epinephrine with a documented weight and route of administration. Only 29 of 104 subjects in the 1994 to 1997 cohort received the correct dose, whereas 46 of 104 subjects received a first dose within 20% of the correct dose. In the 2003 to 2004 cohort, we identified 41 children ≤12 years of age who were in cardiopulmonary arrest and received prehospital epinephrine treatment but 4 children were excluded, leaving 37 subjects. Twenty-one of 37 subjects received the correct dose, whereas 24 of 37 subjects received a dose within 20%. The odds ratio for obtaining the correct epinephrine dose after the system changes versus before was 3.0, and that for obtaining a dose within 20% of the correct dose was 2.5.

CONCLUSIONS. The program seems to have resulted in reduction of the rate of epinephrine dosing errors in the prehospital treatment of children in cardiopulmonary arrest in Los Angeles County.
Primary Care Physicians' Knowledge, Attitudes, and Practices Related to Newborn Hearing Screening
Authors: Moeller Mary Pat , White Karl R. , Shisler Lenore
Published: October 2006

OBJECTIVE. Universal newborn hearing screening focuses on providing the earliest possible diagnosis for infants with permanent hearing loss. The goal is to prevent or minimize the consequences of sensorineural hearing loss on speech and language development through timely and effective diagnosis and interventions. Pediatricians are in a key position to educate families about the importance of follow-up, if they are well informed. The objective of this study was to survey the attitudes, practices, and knowledge of primary care physicians in relation to newborn hearing screening and follow-up.

METHODS. A survey was created on the basis of input from focus groups with primary care physicians. Surveys (n = 12211) were sent to primary care physicians in 21 states and 1 territory (Puerto Rico) regarding practices, knowledge, and attitudes related to universal newborn hearing screening. The response rate was 16.1% (n = 1968).

RESULTS. Physicians reported a high level of support for universal newborn hearing screening; 81.6% judged it to be very important to screen all newborns for hearing loss at birth. Although physicians reported confidence in talking with parents about screening results, they indicated a lack of confidence in discussing follow-up procedures and intervention needs. Several important gaps in knowledge were identified, and these represent priorities for education, as based on their relevance to medical management and parent support. Physicians expressed a strong preference for action-oriented resources.

CONCLUSION. Pediatricians and other primary care providers recognize the benefits of early detection and intervention for permanent hearing loss in infants. The current system of newborn hearing screening can be enhanced by strengthening the medical community's involvement in the process from screening to follow-up. Physician roles will be supported through the provision of action-oriented resources that educate parents about the importance of follow-up and that prepare professionals to incorporate appropriate surveillance procedures in daily practice.
Comorbidity, Hospitalization, and Medication Use and Their Influence on Mental and Motor Development of Young Infants With Down Syndrome
Authors: van Trotsenburg A.S. Paul , Heymans Hugo S.A. , Tijssen Jan G.P. , de Vijlder Jan J.M. , Vulsma Thomas
Published: October 2006

OBJECTIVE. Young infants with Down syndrome have an increased occurrence of several well-known medical conditions such as congenital heart and gastrointestinal disease. The aim of this study was to establish consequences like hospitalization and medication use rates and to determine their possible influence on early neurodevelopment.

PATIENTS AND METHODS. This study compared 2 years of thyroxine treatment with placebo in 196 neonates with Down syndrome who were included in a previously reported randomized clinical trial. Parents were interviewed about comorbidity, hospitalization, and medication use at random assignment and regularly thereafter. Data were cross-checked with discharge letters when available. The influence of comorbidity on neurodevelopment at 2 years old (Bayley Scales of Infant Development II) was determined by stepwise multiple linear-regression analysis.

RESULTS. Before trial entry, 163 infants with Down syndrome had been admitted to hospital for an average of 14.01 days, whereas during the trial, 95 of 181 infants who completed the trial were hospitalized for an average 19.75 days. Main hospitalization reasons during the trial were lung/airway and congenital heart and gastrointestinal disease. The 48 infants operated on for heart or gastrointestinal disease accounted for 1401 of the total number of 1876 hospital admission days during the trial and for 33 of 62 admissions for lung/airway infection. During their second year of life, ∼60% of the infants were prescribed drugs, mostly antibiotics and pulmonary. Regression analysis showed infantile spasms, “other” central nervous system disease, and gastrointestinal disease necessitating surgery to be associated with greater developmental age delays at 24 months old (mental: 6.87, 3.52, and 1.69 months; and motor: 3.59, 2.54, and 1.68 months, respectively).

CONCLUSIONS. Hospital admission and medication use rates in young infants with Down syndrome are still very high, mainly because of congenital heart and gastrointestinal disease and acquired respiratory disease. Central nervous system disease and gastrointestinal disease necessitating surgery were independently associated with a worse developmental outcome.
The Spectrum of Valproic Acid–Associated Pancreatitis
Authors: Werlin Steven L. , Fish Daryl L.
Published: October 2006

OBJECTIVE. Our goal was to characterize valproic acid–associated pancreatitis in children.

PATIENTS AND METHODS. The charts of all patients with pancreatitis (diagnosed by using strict criteria) associated with valproic acid during a 10-year period were reviewed. Clinical and laboratory results were abstracted.

RESULTS. Twenty-two patients with valproic acid–associated pancreatitis were seen during the study period. Symptoms were similar to those of patients with pancreatitis from other etiologies and included abdominal pain/tenderness (83%), vomiting/retching (74%), abdominal distention (30%), and fever/chills (26%). Valproic acid levels were in the therapeutic range in all but 1 patient. The mean duration of therapy before the onset of pancreatitis was 32 months. The serum lipase level was >3 times the reference value in all patients, but the serum amylase level was not significantly elevated in 31% of the patients tested. Imaging studies altered clinical management in only 1 patient. The length of stay was generally brief (mean: 8 days). Two patients died. Of the 5 patients who were rechallenged, 4 had relapses.

CONCLUSIONS. Valproic acid–associated pancreatitis does not depend on valproic acid serum level and may occur any time after the onset of therapy. The serum lipase level is more sensitive than the serum amylase level and should be obtained when pancreatitis is suspected. Early imaging studies did not change clinical management. Rechallenge with valproic acid is dangerous and should be avoided.
Diagnosis and Management of Bronchiolitis
Authors:   Subcommittee on Diagnosis and Management of Bronchiolitis
Published: October 2006

Bronchiolitis is a disorder most commonly caused in infants by viral lower respiratory tract infection. It is the most common lower respiratory infection in this age group. It is characterized by acute inflammation, edema, and necrosis of epithelial cells lining small airways, increased mucus production, and bronchospasm.

The American Academy of Pediatrics convened a committee composed of primary care physicians and specialists in the fields of pulmonology, infectious disease, emergency medicine, epidemiology, and medical informatics. The committee partnered with the Agency for Healthcare Research and Quality and the RTI International-University of North Carolina Evidence-Based Practice Center to develop a comprehensive review of the evidence-based literature related to the diagnosis, management, and prevention of bronchiolitis. The resulting evidence report and other sources of data were used to formulate clinical practice guideline recommendations.

This guideline addresses the diagnosis of bronchiolitis as well as various therapeutic interventions including bronchodilators, corticosteroids, antiviral and antibacterial agents, hydration, chest physiotherapy, and oxygen. Recommendations are made for prevention of respiratory syncytial virus infection with palivizumab and the control of nosocomial spread of infection. Decisions were made on the basis of a systematic grading of the quality of evidence and strength of recommendation. The clinical practice guideline underwent comprehensive peer review before it was approved by the American Academy of Pediatrics.

This clinical practice guideline is not intended as a sole source of guidance in the management of children with bronchiolitis. Rather, it is intended to assist clinicians in decision-making. It is not intended to replace clinical judgment or establish a protocol for the care of all children with this condition. These recommendations may not provide the only appropriate approach to the management of children with bronchiolitis.
ANALYSIS AND TREATMENT OF PROBLEM BEHAVIOR EVOKED BY MUSIC
Authors: Buckley Scott D. , Newchok Debra K.
Published: October 2006

The present study investigated the effects of differential negative reinforcement of other behavior (DNRO) on problem behavior evoked by music in a 7‐year‐old child with pervasive developmental disorder. Following an auditory stimulus assessment, DNRO was used to reduce problem behavior to near‐zero levels. Results are discussed in terms of identifying establishing operations to govern treatment options and the use of negative reinforcement when arbitrarily imposed positive reinforcers do not compete with escape from auditory stimulation.
ENHANCING JOB‐SITE TRAINING OF SUPPORTED WORKERS WITH AUTISM: A REEMPHASIS ON SIMULATION
Authors: Lattimore L. Perry , Parsons Marsha B. , Reid Dennis H.
Published: October 2006

Currently recommended practice in supported work emphasizes training job skills to workers with severe disabilities while on the job. Early behavioral research indicated that skills needed in natural environments could also be trained in simulated settings. We compared job‐site plus simulation training for teaching job skills to supported workers with autism to provision of training exclusively on the job. Job‐site training occurred in a small publishing company during the regular work routine, and simulation training occurred in an adult education site for people with severe disabilities. Two pairs of workers received training on two job skills; one skill was trained at the job site and the other was trained using job‐site plus simulation training. Results indicated that for 3 of the 4 comparisons, job‐site plus simulation training resulted in a higher level of skill or more rapid skill acquisition than did job‐site‐only training. Results suggested that job‐site training, the assumed best practice for teaching vocational skills, is likely to be more effective if supplemented with simulation training. Directions for future research include expanding applications of behavioral technologies to other aspects of the current support paradigm.
A PRELIMINARY EVALUATION OF TWO BEHAVIORAL SKILLS TRAINING PROCEDURES FOR TEACHING ABDUCTION‐PREVENTION SKILLS TO SCHOOLCHILDREN
Authors: Johnson Brigitte M. , Miltenberger Raymond G. , Knudson Peter , Egemo‐Helm Kristin , Kelso Pamela , Jostad Candice , Langley Linda
Published: October 2006

Although child abduction is a low‐rate event, it presents a serious threat to the safety of children. The victims of child abduction face the threat of physical and emotional injury, sexual abuse, and death. Previous research has shown that behavioral skills training (BST) is effective in teaching children abduction‐prevention skills, although not all children learn the skills. This study compared BST only to BST with an added in situ training component to teach abduction‐prevention skills in a small‐group format to schoolchildren. Results showed that both programs were effective in teaching abduction‐prevention skills. In addition, the scores for the group that received in situ training were significantly higher than scores for the group that received BST alone at the 3‐month follow‐up assessment.
THE EFFECTS OF PROMPTING AND FEEDBACK ON DRIVERS' STOPPING AT STOP SIGNS
Authors: Austin John , Hackett Stacey , Gravina Nicole , Lebbon Angela
Published: October 2006

Complete stops at a high‐traffic intersection on the campus of a public university were increased with a prompting and consequence intervention. Data were collected at two opposing stop signs (Stop A and Stop B); however, the intervention was implemented only at Stop A. During the intervention, a volunteer stood next to Stop A holding a poster that read, “Please Stop—I Care,” with “Thank You For Stopping” on the reverse side. The poster was held by the volunteer so that drivers approaching Stop A could read the sign. Drivers approaching Stop B could see the volunteer but could not read the sign. When vehicles approaching Stop A made a complete stop, the volunteer flashed the “thank you” side of the poster to the driver. The strategy was evaluated using a multielement design. The intervention increased stops completed at Stop A from a baseline average of 13% to an intervention average of 52%. Stop B also showed improved stopping, from a baseline average of 6% to an intervention average of 28%. Data showed no relation between complete stops made and the drivers' use of turn signals and safety belts.
Effects of pH, Temperature, and Water Quality on Chloride Removal with Ultra‐High Lime with Aluminum Process
Authors: Abdel‐Wahab Ahmed , Batchelor Bill
Published: October 2006

The ultra high‐lime with aluminum process (UHLA) has the ability to remove sulfate and chloride in addition to other scale‐forming materials from recycled cooling water. Laboratory experiments have demonstrated that the UHLA process can achieve high chloride removal from recycled cooling water, and an equilibrium model was developed to describe chemical behavior during chloride removal. This paper describes the influence of pH, temperature, and initial chloride concentration on chloride removal by UHLA and identifies the precipitated solids formed during treatment. The optimum pH for maximum chloride removal efficiency was found to be 12 ± 0.2. Chloride removal efficiency was higher at a high initial chloride concentration than at a low initial chloride concentration with the chemical doses used. Solids formed during UHLA treatment were identified by x‐ray diffraction as calcium chloroaluminate, tricalcium hydroxyaluminate, and tetracalcium hydroxyaluminate. This supports the assumption of the equilibrium model that these compounds are present and form a solid solution.
Crystalline Hydrous Ferric Oxide: An Adsorbent for Chromium(VI)‐Contaminated Industrial Wastewater Treatment
Authors: Goswami Saswati , Bhat Subhas Chandra , Ghosh Uday Chand
Published: October 2006

Synthetic crystalline hydrous ferric oxide (CHFO) (particle size 0.14 to 0.29 mm) has been used systematically for adsorptive chromium(VI) removal from contaminated water. Batch experiments were performed as a function of pH, contact time, solute concentration, and regeneration of adsorbents. Column experiments were performed for breakthrough points in the presence and absence of other ions and treatment of industrial effluent. The optimum pH range was 2.0 to 4.0. The adsorption kinetic data could be described well by both second‐order and pseudo‐first‐order models. The isotherm adsorption data at 30 ± 2°C obeyed the Langmuir model best. The monolayer adsorption capacity was 35.7 mg/g. Chromium(VI)‐rich CHFO could be regenerated up to 89 ± 1% with 2.0 M sodium hydroxide. Regenerated column reuse showed a decrease (10 to 12%) in breakthrough capacity. Finally, the CHFO‐ (dried at 300°C) packed column was used for the recovery (98.5 ± 1.0%) of chromium(VI) from contaminated industrial waste effluent of Hindustan Motor Limited (Hooghly, West Bengal, India).
Winter and spring evaluations of a wetland for tertiary wastewater treatment
Authors: Stober J. Trent , O'Connor John T. , Brazos Blaise J.
Published: October 2006

The Union Electric Callaway Nuclear Power Plant currently uses a wetland that evolved after the retirement of a water treatment lagoon to supplement the existing mechanical wastewater treatment plant. The purpose of this study was to evaluate the wastewater treatment performance of the evolved wetland. Removal of biochemical oxygen demand (BOD), chemical oxygen demand (COD), total suspended solids (TSS), ammonium, nitrate, phosphate, and sulfate were monitored during winter 1992 and early spring 1993. Hydraulic and hydrologic assessments were also conducted to determine the effective treatment area and actual detention times. The organic loading during the study was low, resulting in moderate decreases or increases in BOD, COD, TSS, and ammonium. The wetland system provided excellent reduction in phosphate, nitrate, and sulfate. Removal of all constituents was significantly greater during the early spring sampling period than the winter period. Increased performance was probably caused by increased surface water temperature, vegetative uptake, and greater detention times. A large amount of short circuiting was observed within the system, reducing detention time and wastewater treatment performance.
General model for biological nutrient removal activated‐sludge systems: model application
Authors: Barker P.S. , Dold P.L.
Published: October 2006

The application of a general model for nitrification denitrification biological excess phosphorus removal (NDBEPR) activated‐sludge systems is demonstrated. Results of simulations show the model is capable of predicting sludge production and oxygen use for a range of system types and configurations, and of tracking changes in a number of parameters including soluble phosphorus and nitrate concentrations. Application of the model is demonstrated for aerobic and anoxic–aerobic systems and for a number of nutrient removal systems for both steady‐state and for dynamic conditions.