bluuebunny/crossref_metadata_2025 huggingface dataset:
A Randomized Controlled Trial of Point-of-Care Evidence to Improve the Antibiotic Prescribing Practices for Otitis Media in Children
Authors: Christakis Dimitri A. , Zimmerman Frederick J. , Wright Jeffrey A. , Garrison Michelle M. , Rivara Frederick P. , Davis Robert L.
Published: August 2004

Context.

Prescribing practices for otitis media are not consistent with current evidence-based recommendations.

Objective.

To determine whether point-of-care evidence delivery regarding the use and duration of antibiotics for otitis media decreases the duration of therapy from 10 days and decreases the frequency of prescriptions written.

Design.

Randomized, controlled trial.

Setting.

Primary care pediatric clinic affiliated with university training program.

Intervention.

A point-of-care evidence-based message system presenting real time evidence to providers based on their prescribing practice for otitis media.

Main Outcome Measures.

Proportion of prescriptions for otitis media that were for <10 days and frequency with which antibiotics were prescribed.

Results.

Intervention providers had a 34% greater reduction in the proportion of time they prescribed antibiotics for <10 days. Intervention providers were less likely to prescribe antibiotics than were control providers.

Conclusions.

A point-of-care information system integrated into outpatient pediatric care can significantly influence provider behavior for a common condition.
Trends in the Rural-Urban Distribution of General Pediatricians
Authors: MD Greg D. Randolph , MD Donald E. Pathman
Published: August 2004

Objective.

A major objective of national and state health policy has been to increase primary care physician supply in rural areas. It is not known whether this objective has been met for general pediatricians. This study examines trends in the rural-urban distribution of general pediatricians in the United States from 1981 to 1996.

Design.

Descriptive serial cross-sectional study.

Participants.

At selected 5-year intervals, all clinically active general pediatricians in the United States listed in the American Medical Association Physician Masterfile.

Main Outcome Measures.

The proportion of pediatricians practicing in rural counties and the ratio of pediatricians to the child population (per 100 000 children <18 years old) for US counties.

Results.

Between 1981 and 1996, the total number of general pediatricians increased from 19 739 to 34 100. However, rural pediatrician-to-child population ratios (PCPRs) remained well below urban ratios. Although rural counties of all population sizes experienced some gains over time, only those over 25 000 populations had a meaningful increase in their PCPR. Overall, the urban PCPR increased by 14.0 (or an additional pediatrician for every 7150 children) whereas the rural ratio only increased by 4.1 (an additional pediatrician for every 24 400 children). The percentage of recent residency graduates opting for rural practice declined by half (14.6% to 7.4%) over the 15-year study period. Women and international graduates were consistently less likely to practice in rural counties than were men and US graduates, respectively.

Conclusions.

The near doubling in general pediatrician numbers from 1981 to 1996 yielded only a modest increase in pediatrician availability for rural children. The discrepancy between urban and rural pediatrician supply increased during this period and should continue growing based on the increasingly urban location of recent residency graduates and the continued growth of women in pediatrics. New policy strategies are needed to improve rural pediatrician availability, including focusing on larger rural counties and addressing barriers to rural practice for women. pediatrics/manpower, pediatrics/trends, rural health, physicians/supply and distribution, medically underserved area.
Circumcision: We Have Heard From the Experts; Now Let's Hear From the Parents
Authors: Adler Robert , Ottaway MsED*; Sandra , Gould Stacey
Published: August 2004

Objective.

The current study sought to investigate parental attitudes about circumcision and their satisfaction with the decision.

Methodology.

Parents of boys (6 months to 36 months old) in 3 different practices filled out a questionnaire while waiting for their child's well-child examination.

Results.

A total of 149 families were surveyed. Families (68) who did not have their sons circumcised were less satisfied with their decision. Compared with families (81) of circumcised children, parents of uncircumcised boys were less likely to have been asked by their physician about whether they wanted their child circumcised, believed that they did not receive adequate information about the procedure, felt less respected by their medical provider, and were more likely to reconsider their decision.

Conclusion.

The importance of adequate information and discussion is highlighted by this study.
A Case-Crossover Study of Sleep and Childhood Injury
Authors: Valent Francesca , Brusaferro Silvio , Barbone Fabio
Published: August 2004

Objective.

To evaluate the association between sleep and wakefulness duration and childhood unintentional injury.

Study Design.

Case-crossover study.

Methods.

Two hundred ninety-two injured children who presented at the Children's Emergency Center of Udine, Italy, or their parents were interviewed after a structured questionnaire. Information was collected concerning sociodemographic variables, participant's habits, and injury characteristics, including a brief description of the accident dynamics. Sleep or wakefulness status of the child was assessed retrospectively for each of the 48 hours before injury. For each child, we compared the 24 hours immediately before the injury (hours 1–24; case period) with hours 25 to 48 (control period). Nonparametric tests were conducted to compare the difference of sleep duration between case and control periods. In addition, we conducted intrapersonal conditional logistic regression analyses and estimated relative risks (RRs) and 95% confidence intervals (CIs).

Results.

Overall, more children had longer hours of sleep during the control period than during the case period. However, this difference was significant for boys only. A direct association between injury risk and sleeping <10 hours was found among boys (RR: 2.33; 95% CI: 1.07–5.09) but not among girls (RR: 1.00; 95% CI: .29–3.45). This association was particularly strong among boys attending nursery school. We also found a direct association between injury occurring between 4 pm and midnight, and being awake for at least 8 hours before injury occurred (both sexes, RR: 4.00; 95% CI: 1.13–14.17).

Conclusions.

Our findings show that inadequate sleep duration and lack of daytime naps are transient exposures that may increase the risk of injury among children. These results suggest new prospects for injury prevention in childhood. children, injury, sleep, case-crossover, epidemiology.
Pediatric Peripherally Inserted Central Catheters: Complication Rates Related to Catheter Tip Location
Authors: Racadio John M. , Doellman Darcy A. , Johnson Neil D. , Bean Judy A. , Jacobs Brian R.
Published: August 2004

Objective.

To compare complication rates between central venous catheter tip location and noncentral tip location after peripherally inserted central catheter (PICC) placement in children.

Methods.

Between 1994 and 1998, data from all children who underwent PICC placement were analyzed. Patient demographics, catheter characteristics, catheter duration, infusate composition, and catheter complications were entered prospectively into a computerized database. Catheter tip locations were determined by fluoroscopy and were defined as central if they resided in the superior vena cava, right atrium, or high inferior vena cava at or above the level of the diaphragm, and as noncentral if located elsewhere. Differences in complication rates between the central and noncentral groups were analyzed.

Results.

Data from a total of 1266 PICCs were analyzed from 1053 patients with a mean age of 6.49 ± .2 years (range: 0–45.0 years). Of the 1266 PICCs, 1096 (87%) were central in tip location, and 170 (13%) were noncentral in tip location. The central group had 42 complications of 1096 catheters (3.8%), while the noncentral group had 49 complications of 170 catheters (28.8%). Controlling for patient age, catheter size, gender, and catheter duration with a logistic regression model, there remained a statistically significant increased likelihood of complication in the noncentral group versus the central group (adjusted odds ratio: 8.28; 95% confidence interval: 5.11–13.43).

Conclusions.

Centrally placed catheter tips are associated with fewer complications than are noncentrally placed catheter tips. Clinicians should ensure that catheter tips reside centrally after PICC placement in infants and children.
Combined Use of Electroencephalogram and Magnetic Resonance Imaging in Full-Term Neonates With Acute Encephalopathy
Authors: Biagioni Enrico , Mercuri Eugenio , Rutherford Mary , Cowan Frances , Azzopardi Denis , Frisone Maria F. , Cioni Giovanni , Dubowitz Lilly
Published: August 2004

Objective.

The electroencephalogram (EEG) is widely used in full-term infants with acute neonatal encephalopathy, and its prognostic value has been confirmed by several studies. Magnetic resonance imaging (MRI) of the brain has also been applied in these patients, and increasing numbers of reports affirm its prognostic reliability. The aim of this study has been to investigate the correlation between an early EEG and MRI findings in infants with acute neonatal encephalopathy and to assess the prognostic value of a combination of EEG and MRI findings.

Participants and Methods.

Twenty-five full-term infants had an EEG recorded within the first 72 hours after birth and a neonatal brain MRI scan after the end of the first week.

Results.

Both EEG and MRI were predictive of outcome. A normal MRI was always associated with normal EEG background activity and normal outcome and severe abnormalities on MRI with marked EEG abnormalities and an abnormal outcome. When the MRI showed moderate abnormalities, the EEG in all cases but one identified patients with normal and abnormal outcome.EEG, MRI, HIE, neurodevelopment.
Neurodevelopmental Outcome of Infants Treated With Head Cooling and Mild Hypothermia After Perinatal Asphyxia
Authors: Battin Malcolm R. , Dezoete J. Anne , Gunn Tania R. , Gluckman Peter D. , Gunn Alistair J.
Published: August 2004

Objectives.

To determine the neurodevelopmental outcome of infants treated with head cooling with systemic hypothermia after hypoxic-ischemic encephalopathy.

Study Group.

Infants ≥37 weeks' gestation, who had an umbilical artery pH ≤7.09 or Apgar score ≤6 at 5 minutes, plus clinical encephalopathy. Infants with major congenital abnormalities were excluded.

Trial Design.

Infants were allocated to either no cooling (rectal temperature = 37.0 ± 0.2°C, n= 15), or, sequentially, to head cooling accompanied by different levels of systemic hypothermia, including minimal cooling, rectal temperature 36.5°C to 36°C (n = 6), and mild cooling, to either 35.9°C to 35.5°C (n = 6), 35 ± 0.5°C (n = 6) or 34.5 ± 0.5°C (n = 7). Head cooling was accomplished by circulating cooled water through a coil of tubing wrapped around the head for up to 72 hours. Survivors were followed up with regular neurologic examination by a neonatologist until 18 months of age, then with blinded developmental testing using the revised Bayley Scales.

Results.

A total of 40 term infants were enrolled from 2 to 5 hours after birth. The control and the cooled groups were not significantly different for gestation, birth weight, Apgar score, and initial pH. There were 6 early neonatal deaths (3 normothermic and 3 cooled), and 1 death in infancy associated with severe spastic cerebral palsy in a normothermic infant. Six normothermic, 1 minimally cooled, and 4 mildly cooled infants had early stage 1 encephalopathy; all but 1 had a good outcome. Among infants with early stage 2 or 3 encephalopathy, an adverse outcome was found in 4 of 9 normothermic infants (44%) and 4 of 5 minimally cooled infants (80%), whereas in the combined mildly cooled groups, an adverse outcome was found in 4 of 15 infants (26%, odds ratio 0.46 [0.08, 2.56] vs normothermia).

Conclusions.

The present study supports the safety of hypothermia, with no evidence of late adverse effects in any infant. Among infants with moderate to severe encephalopathy at enrollment, there was a tendency toward better outcome. These results emphasize the relatively wide range of outcomes using purely clinical criteria for enrollment. Therapeutic hypothermia should not be used outside of stringent, multicenter trials.
Adolescent Suicide Attempts: Risks and Protectors
Authors: Borowsky Iris Wagman , Ireland Marjorie , Resnick Michael D.
Published: August 2004

Objective.

In 1997, suicide was the third leading cause of death among 10- to 19-year-olds in the United States, with the greatest increases in suicide rates in the previous decade experienced by black and other minority youth. The purpose of this study was to identify risk and protective factors for suicide attempts among black, Hispanic, and white male and female adolescents.

Methods.

We used data from the National Longitudinal Study of Adolescent Health, conducted in 1995 and 1996. A nationally representative sample of 13 110 students in grades 7 through 12 completed 2 in-home interviews, an average of 11 months apart. We examined Time 1 factors at the individual, family, and community level that predicted or protected against Time 2 suicide attempts.

Results.

Perceived parent and family connectedness was protective against suicide attempts for black, Hispanic, and white girls and boys, with odds ratios ranging from 0.06 to 0.32. For girls, emotional well-being was also protective for all of the racial/ethnic groups studied, while a high grade point average was an additional protective factor for all of the boys. Cross-cutting risk factors included previous suicide attempt, violence victimization, violence perpetration, alcohol use, marijuana use, and school problems. Additionally, somatic symptoms, friend suicide attempt or completion, other illicit drug use, and a history of mental health treatment predicted suicide attempts among black, Hispanic, and white females. Weapon-carrying at school and same-sex romantic attraction were predictive for all groups of boys. Calculating the estimated probabilities of attempting suicide for adolescents with increasing numbers of risk and protective factors revealed that the presence of 3 protective factors reduced the risk of a suicide attempt by 70% to 85% for each of the gender and racial/ethnic groups, including those with and without identified risk factors.

Conclusions.

In these national samples of black, Hispanic, and white youth, unique and cross-cutting factors derived from a resiliency framework predicted or protected against attempting suicide. In addition to risk reduction, promotion of protective factors may offer an effective approach to primary as well as secondary prevention of adolescent suicidal behavior.
Analysis of Nonsteroidal Antiinflammatory Drugs in Meconium and Its Relation to Persistent Pulmonary Hypertension of the Newborn
Authors: Alano Maria Andrea , Ngougmna Etienne , Ostrea Enrique M. , Konduri G. Ganesh
Published: August 2004

Objective.

The objective of this study was to detect fetal exposure to nonsteroidal antiinflammatory drugs (NSAIDs) by meconium analysis and to determine the relationship between fetal exposure to NSAIDs and the development of persistent pulmonary hypertension of the newborn (PPHN).

Methods.

In a case-control study of the inborn and outborn nurseries of a large urban medical center, meconium was collected from 101 newborn infants (40 with the diagnosis of PPHN based on clinical or echocardiographic criteria and 61 randomly selected, healthy, term infants [control]) and analyzed for NSAIDs (ibuprofen, naproxen, indomethacin, and aspirin) by gas chromatography/mass spectrometry. The risk of developing PPHN was determined in infants who were exposed antenatally to NSAID.

Results.

Infants with PPHN (n = 40) had a mean gestation of 38.9 weeks and birth weight of 3524 g, which were similar to the those of the control group (n = 61). However, the incidence of low Apgar scores (≤6) at 1 minute and 5 minutes was significantly higher in the PPHN group than in the control group. The diagnoses associated with PPHN were primary PPHN (25%), meconium aspiration syndrome (35%), respiratory distress syndrome (20%), low Apgar score/asphyxia (12.5%), and pneumonia/sepsis (8%). Mean duration of ventilator support for the PPHN group was 11 days. Nitric oxide (NO) was given to 19 infants (47.5%) for a mean duration of 25.4 hours. Fourteen of the 19 infants who were treated with NO (74%) required extracorporeal membrane oxygenation, and 2 died. The overall incidence of positive NSAID in meconium in the study population (n = 101) was 49.5%: 22.8% were positive for ibuprofen, 18.8% for naproxen, 7.9% for indomethacin, and 43.6% for aspirin. There was poor agreement (Cohen's κ = 0.09) between maternal history of NSAID use and NSAID detection in meconium. PPHN was significantly associated with 1) the presence of at least 1 NSAID in meconium (odds ratio [OR] = 21.47; 95% confidence interval [CI] = 7.12–64.71) or 2) the presence in meconium of aspirin (OR = 8.09; 95% CI = 3.27–20.10), ibuprofen (OR = 12.89; 95% CI 3.93–42.32), or naproxen (OR = 3.31; 95% CI = 1.17–9.33). By logistic regression analysis, low Apgar scores at 1 and 5 minutes and the antenatal exposure to aspirin, naproxen, and ibuprofen were significantly associated with PPHN and treatment with inhaled NO or extracorporeal membrane oxygenation.

Conclusion.

We confirm by meconium analysis the results of previous studies that demonstrated that the use of NSAIDs during pregnancy, particularly aspirin, ibuprofen, and naproxen, is high; is grossly underestimated by maternal history; and is significantly associated with PPHN. Thus, the easy access to over-the-counter NSAIDs of pregnant women should be reevaluated, and the potential dangers of these drugs to the newborn infant should be more effectively promoted.
Environmental Tobacco Smoke and Serum Vitamin C Levels in Children
Authors: Strauss Richard S.
Published: August 2004

Background. 

High levels of free radicals in tobacco smoke are thought to be responsible for decreased levels of serum ascorbic acid in smokers and adults exposed to environmental tobacco smoke (ETS). The association of ETS to serum ascorbic acid in children is unknown.

Methods.

Data were analyzed from the Third National Health and Nutrition Examination Survey, a nationally representative sample of children and adolescents (n = 2968). Comprehensive data including serum cotinine levels and family smoking patterns allowed for analysis of relationship of ETS to serum ascorbic acid levels. Data from 24-hour dietary recall also allowed for the control of vitamin C intake. Children were divided into categories of low and high ETS exposure based on levels of serum cotinine above or below 2 ng/mL. Smokers were defined by either self-report or serum cotinine >15 ng/mL.

Results.

Although there was a trend for lower levels of vitamin C intake in children with higher levels of ETS exposure, this trend did not reach statistical significance. Among all children, serum ascorbic acid levels were linearly related to serum cotinine levels (r = 0.19). In addition, a dose-response relationship was observed between levels of tobacco exposure and serum ascorbic acid levels. After adjusting for age, gender, vitamin C intake, and multivitamin use, environmental tobacco exposure remained significantly associated with lower levels of serum ascorbic acid in children who were exposed to both high and low levels of ETS.

Conclusion.

Exposure of children to ETS leads to significant alterations in serum ascorbic acid levels. Therefore, this study further highlights the potential dangers of ETS to children.
Contraception in the Adolescent: An Update
Authors: Greydanus Donald E. , Patel Dilip R. , Rimsza Mary Ellen
Published: August 2004

Contraception remains an important part of national efforts to reduce adolescent pregnancy in the United States. A number of safe and effective contraceptive methods are available for our youth, including abstinence, barrier methods, oral contraceptives, Depo-Provera, and Norplant. Research over the past few decades has resulted in a variety of oral contraceptives with reduced amounts of hormones and reduced side-effects. A number of methods have received approval by the Food and Drug Administration since the last review in 1980, including emergency contraceptives, depomedroxyprogesterone acetate, and the cervical cap. The use of condoms and vaginal spermicides continues to be recommended for all sexually active adolescents to reduce (not eliminate) the risk for acquiring sexually transmitted diseases. A polyurethane condom is now available, in addition to the latex condom and other barrier contraceptives, including the following: diaphragm, cervical cap, vaginal sponge, female condom and vaginal spermicides. Because of continuing concerns about pelvic inflammatory disease related to intrauterine devices, currently available intrauterine devices are not recommended for most adolescents. Abortion is not considered as a contraceptive method.
Minimizing False-Positives in Universal Newborn Hearing Screening: A Simple Solution
Authors: Clemens Conrad J. , Davis Sherri A.
Published: August 2004

Background and Objectives. 

The false-positive rates of previously reported universal newborn hearing screening (UNHS) programs range between 2.5% and 8%. Critics of UNHS programs have claimed that this rate is too high and might lead to a number of the negative effects produced by false-positive screening tests, namely emotional trauma, disease labeling, iatrogenesis from unnecessary testing, and increased expense in terms of time and money.

We previously reported, based on some preliminary data, that as many as 80% of newborns who failed the initial hearing screen subsequently passed when they were retested the following day, before being discharged from the hospital. We now present the results of this intervention for our entire UNHS program during a 7-month period.

Methods.

We analyzed data from 3142 non-neonatal intensive care unit infants screened with an automated auditory brainstem response at the Women's Hospital of Greensboro from November 1, 1999 to May 31, 2000. A protocol was developed wherein all infants who failed the initial UNHS were rescreened with another automated auditory brainstem response before hospital discharge. Data collected included pass/fail rates during the inpatient stay as well as follow-up data and risk factors for congenital hearing loss.

Results.

Confirmed hearing loss occurred in 8 nonneonatal intensive care unit infants, a rate of 2.5/1000. Eighty percent of newborns who failed the initial hearing screen passed on rescreening before hospital discharge. This produced a false-positive rate of 0.8% and a corresponding positive predictive value of 24%. If inhospital rescreening had not occurred, our false-positive rate and positive predictive value would have been 3.9% and 6.1%, respectively.

Conclusions.

Our simple intervention of rescreening all infants who failed their initial UNHS before hospital discharge reduced the false-positive rate of UNHS to 0.8%. We suggest that this simple, inexpensive intervention should be instituted for all similar UNHS programs.
Vaccination Coverage and Physician Distribution in the United States, 1997
Authors: LeBaron Charles W. , Massoudi Mehran , Stevenson John , Lyons Bridget
Published: August 2004

Background.

How many physicians are needed in the United States and how they should be allocated geographically and among specialties has been the subject of intense debate, a debate that has often focused more on costs to third-party payers and government than on benefits to health. Child health is a central aspect of public health, and immunization is one of its most cost-effective and easily measured interventions.

Objective.

To examine the association of immunization rates and delivery characteristics with the distribution of child health physicians in the United States in 1997.

Design.

Cross-sectional ecological study, using the state as the unit of analysis, immunization rates and delivery characteristics (from the National Immunization Survey) as the main outcome measures, concentration of the principal physician specialties providing routine care to children (pediatric, family, and general physicians from the American Medical Association Masterfile) as the main risk factor, while controlling for demographic and economic factors (from the Bureau of the Census and other sources).

Results.

Of the 96 689 physicians providing routine care to children, 37% were pediatric, 49% family, and 14% general physicians. Higher rates of vaccination, private sector vaccination, and increased numbers of public and private vaccination sites were all associated with the concentration of pediatricians but not of family or general physicians. The distribution of pediatricians was strongly associated with the distribution of residency positions.

Conclusions.

Pediatrician distribution is a strong correlate to immunization rates and delivery characteristics. Opportunities to affect pediatrician distribution may exist with allocation of residency positions.
Incidence Survey of Kawasaki Disease in 1997 and 1998 in Japan
Authors: Yanagawa Hiroshi , Nakamura Yosikazu , Yashiro Mayumi , Oki Izumi , Hirata Shizuhiro , Zhang Tuohong , Kawasaki Tomisaku
Published: August 2004

Objective.

To describe the results of a nationwide epidemiologic survey of Kawasaki disease for the 2-year period 1997 and 1998.

Design.

We sent a questionnaire to all hospitals with 100 beds or more throughout Japan (2663 hospitals) requesting data on patients with Kawasaki disease. Study items included name, sex, date of birth, date of initial hospital visit, diagnosis, address, recurrence, sibling cases, gammaglobulin treatment, and cardiac lesion in the acute stage or 1 month after onset.

Results.

Of the 2663 hospitals, 68.5% responded, reporting 12 966 patients—7489 males and 5477 females. Of the total patients reported, 6373 (incidence rate of 108.0 per 100 000 children <5 years old) occurred in 1997, and 6593 (111.7) in 1998. More than one half of the patients (54.9%) were <2 years old and 81.6% were <4 years old. In males, the incidence rates of cardiac lesions were 27.2 in the acute stage and 10.1 a month after onset. In females, the rates were 16.7 and 5.2, respectively. The incidence rates of cardiac lesions were highest in the youngest age group (<6 months old) both in the acute stage and 1 month after onset. The rates decreased with increasing ages. Although frequency of giant aneurysms was not high at the acute stage, it did not decrease 1 month after onset.

Conclusion.

The incidence rates have been steadily increasing for 11 years since 1987. The rate in 1998 was over 1.5 times higher than that in 1987. The age and sex distributions were identical in each survey. Although most of the cardiac lesions at the acute stage decreased to half or less 1 month after onset, giant aneurysms did not decrease and existed persistently after 1 month.
Psychological Adjustment of Adolescent Girls With Chronic Fatigue Syndrome
Authors: van Middendorp Henriët , Geenen Rinie , Kuis Wietse , Heijnen Cobi J. , Sinnema Gerben
Published: August 2004

Objective.

To examine psychosocial problems and adaptation of adolescent girls with chronic fatigue syndrome (CFS).

Methodology.

Thirty-six adolescent girls with CFS (mean age: 15.2 years; mean syndrome duration: 19.7 months) who fulfilled the criteria of the Centers for Disease Control and Prevention were examined by interviews regarding premorbid problems and by questionnaires regarding psychosocial functioning and distress, psychological attitudes, and coping resources. Data were compared with normative data.

Results.

Of the adolescents, 86.1% reported 1 or more premorbid problems (58.3% physical, 38.9% psychological, and 52.8% familial). Normal adjustment was reported for psychosocial self-esteem, social abilities, and attentional abilities. High adjustment to adult social standards of behavior was found, but low perceived competence in specific adolescent domains, such as athletic ability, romance, and participation in recreational activities. The girls reported predominantly internalizing problems. Normal achievement motivation, no debilitating fear of failure, and high internal locus of control were observed. Palliative reaction patterns and optimism were predominantly used as coping strategies.

Conclusions.

The large number of premorbid problems suggests a possible contributing factor to the onset of the syndrome, although there were no reference data of healthy adolescents. In distinct domains of psychosocial adjustment, the adolescent girls with CFS showed strengths such as adequate self-esteem and scholastic and social abilities, and weaknesses such as low competence in adolescent-specific tasks and internalizing distress, which may partly be explained by syndrome-specific somatic complaints. The use of optimistic and palliative reaction patterns as coping strategies in this patient group indicates that the patients with CFS seem to retain an active and positive outlook on life, which may result in a rather adequate psychological adaptation to the syndrome, but also in maintenance of the syndrome by exceeding the physical limits brought about by the CFS. Our results on adjustment and coping strategies may be helpful to implement (individual) rehabilitation programs.
Delayed Hypersensitivity to Tuberculin, Total Immunoglobulin E, Specific Sensitization, and Atopic Manifestation in Longitudinally Followed Early Bacille Calmette-Guérin-Vaccinated and Nonvaccinated Children
Authors: Grüber Christoph , Kulig Michael , Bergmann Renate , Guggenmoos-Holzmann Irene , Wahn Ulrich ,   the MAS-90 Study Group
Published: August 2004

Background.

Bacille Calmette-Guérin (BCG) is a strong T helper 1 incentive and, thus, may contribute to a decreased risk of T helper 2-dependent atopic disease.

Objective.

To investigate the natural course of specific immunoglobulin E (IgE) responses and atopic disease in BCG-vaccinated and nonvaccinated children.

Participants.

Seven hundred seventy-four children from a prospectively followed birth cohort.

Outcome Measures.

Physical examination and case history were performed at 3, 6, 12, 18, 24, 36, 48, 60, 72, and 84 months of age. Total and specific serum IgE levels to 9 common inhalant and food allergens were determined (CAP; Pharmacia, Freiburg, Germany) at 12, 24, 36, 60, 72, and 84 months of age. Purified protein derivative (PPD) skin testing was performed at 84 months.

Results.

Period and lifetime prevalences of atopic dermatitis and recurrent wheezing tended to be lower in the BCG-vaccinated group early in life, whereas no such trend was found after the second birthday or for allergic rhinitis. The proportion of children remaining free of clinical manifestations tended to be higher in the BCG-vaccinated group but differences decreased over time. No statistically significant differences were found for total IgE levels (median). Atopic sensitization tended to be lower among BCG-vaccinated children during the first 2 years of life. The diameter of the skin reaction to PPD did not correlate with total serum IgE. Clinical and serologic correlates of atopy were not significantly different between children with a skin test diameter of ≥5 mm and those with a smaller diameter.

Conclusion.

These results do not support the hypothesis that BCG vaccination in early infancy is associated with a subsequently markedly decreased risk of atopic sensitization or allergy. In addition, PPD skin test reactivity was not impaired in atopic individuals.
Solids and Formula: Association With Pattern and Duration of Breastfeeding
Authors: Hörnell Agneta , Hofvander Yngve , Kylberg Elisabeth
Published: August 2004

Objectives.

To study changes in pattern and duration of breastfeeding associated with the introduction of solids and formula.

Study Design.

Descriptive longitudinal, prospective study.

Setting.

The participants were recruited from the maternity ward in the University Hospital in Uppsala, Sweden, between May 1989 and December 1992. A total of 15 189 infants were born during the period, 1 177 mother–infant pairs were found eligible for participation; 57% declined because of the perceived high workload.

Study Population.

Five hundred six mother–infant pairs.

Methods.

Daily recordings by the mothers on infant feeding, from the first week after delivery to the second menstruation postpartum or a new pregnancy; fortnightly home visits with structured interviews by a research assistant.

Results.

Introduction of solids was associated with no or minor changes in breastfeeding frequency and suckling duration. Breastfeeding frequency remained constant the first month after the introduction and then declined slowly, while daily suckling duration started to decline slowly when solids were introduced. Breastfeeding duration was not associated with infants' age at introduction of solids. In infants given formula, as soon as regular formula feeds started, the breastfeeding frequency and suckling duration declined swiftly. The younger an infant was at the start of regular formula feeds, the shorter the breastfeeding duration.

Conclusions.

Health care personnel and parents need to be aware that introduction of solids and introduction of formula can have very different consequences for breastfeeding. If the aim is to introduce other foods to breastfed infants under the protection of breast milk, it is important to realize that formula is also another food and needs to be treated as such.
Levels of Interleukin-2, Interferon-γ, and Interleukin-4 in Bronchoalveolar Lavage Fluid From Patients WithMycoplasmaPneumonia: Implication of Tendency Toward Increased Immunoglobulin E Production
Authors: Koh Young Yull , Park Yang , Lee Hoan Jong , Kim Chang Keun
Published: August 2004

Objective.

In connection with the possible relationship between Mycoplasma infection and the onset of asthma, several studies have shown not only a high level of serum total immunoglobulin E (IgE) but also the production of IgE specific to Mycoplasma or common allergens during the course of Mycoplasma infection. It has been suggested that the balance of T helper type 1 (TH1)/T helper type 2 (TH2) immune response may regulate the synthesis of IgE. The objective of this study was to investigate the pattern of cytokine response (TH1 or TH2) during an episode of acute lower respiratory tract infection caused byMycoplasma pneumoniae.

Study Design.

Using a bronchoalveolar lavage (BAL) with flexible bronchoscopy procedure, this study determined the levels of interleukin (IL)-2, interferon (IFN)-γ (TH1), and IL-4 (TH2) in the supernatant of BAL fluid as well as the BAL cellular profiles of patients with Mycoplasma pneumonia (n = 14). These results were compared with those of patients with pneumococcal pneumonia (n = 12) or those of children with no identifiable airway infections (control group: n = 8).

Results.

The BAL cellular profile in theMycoplasma pneumonia group was characterized by a high percentage of neutrophils and lymphocytes. A significantly increased level of IL-2 was found in both pneumonia groups, compared with the control group. In contrast, the IFN-γ level was not different for the 3 groups. The level of IL-4 and ratio of IL-4/IFN-γ were significantly elevated in the Mycoplasma pneumonia group, but not in the pneumococcal pneumonia group, compared with the controls.

Conclusions.

IL-4 levels and IL-4/IFN-γ ratios in BAL fluid are significantly higher in patients withMycoplasma pneumonia than in patients with pneumococcal pneumonia or control participants. The BAL cytokine data suggest a predominant TH2-like cytokine response in Mycoplasmapneumonia, thus representing a favorable condition for IgE production.
Subcutaneous Granuloma Annulare in Childhood: Clinicopathologic Features in 34 Cases
Authors: Grogg Karen L. , Nascimento Antonio G.
Published: August 2004

Objective.

To gather clinicopathologic data on subcutaneous granuloma annulare (SGA), a subtype of granuloma annulare that occurs exclusively in children and is histologically similar to rheumatoid nodules.

Design.

Retrospective record review.

Patients.

Children <10 years old in whom SGA, deep granuloma annulare, or necrobiotic granuloma was diagnosed at the Mayo Clinic (Rochester, MN) from 1983 to 1998.

Results.

Thirty-four patients (21 girls and 13 boys; average age at diagnosis: 4.6 years) were found to have SGA. The lesions predominantly occurred in the lower extremity, especially in a pretibial location. Local recurrence within 1 month to 7 years was documented in 38.2%; recurrence at other locations was documented in 14.7%. Average follow-up was 60 months; during follow-up, no patients developed signs or symptoms of rheumatologic disease. Insulin-dependent diabetes mellitus was diagnosed in 2 patients, 1 before the development of SGA and 1 after it by 1 month.

Conclusions.

SGA is a lesion that presents as subcutaneous nodules on the lower extremities, hands, or scalp in young children. Recurrence is common but usually does not warrant additional biopsy.
Multicenter, Randomized, Double-Blind Clinical Trial to Evaluate the Efficacy and Safety of a Reduced Osmolarity Oral Rehydration Salts Solution in Children With Acute Watery Diarrhea
Authors:   CHOICE Study Group
Published: August 2004

Objective.

To compare the efficacy of a reduced osmolarity oral rehydration salts (ORS) solution (75 mmol/L of sodium [Na], 20 mmol/L of potassium [K], 65 mmol/L of chloride, 10 mmol/L of citrate, and 75 mmol/L of glucose; osmolarity, 245 mosm/L) with that of the standard World Health Organization (WHO) ORS solution.

Design.

A multicenter, double-blind, randomized, controlled clinical trial conducted in children with acute diarrhea in 5 developing countries to measure mean stool output in the 24 hours after randomization, proportion of children who required unscheduled intravenous therapy, proportion of children who vomited in the first 24 hours, and diarrhea duration after randomization.

Results.

A total of 675 children who ranged in age from 1 to 24 months and who had acute diarrhea and dehydration were enrolled in the trial; 341 were randomized to receive reduced osmolarity ORS solution, and 334 were randomized to receive the WHO ORS solution. The mean (SE) stool output (g/kg) in the first 24 hours (reduced osmolarity ORS solution vs WHO ORS solution = 114 [4] vs 125 [5]) and during the total study period (reduced osmolarity ORS solution vs WHO ORS solution = 320 [18] vs 331 [18]) were comparable. The proportion of children who vomited in the first 24 hours (reduced osmolarity ORS solution vs WHO ORS solution = 58% vs 62%) and the diarrhea duration in the 2 treatment groups, compared by log rank test, were similar. The proportion of children who required unscheduled intravenous therapy was significantly lower in children who received reduced osmolarity ORS solution (10%) as compared with those who received the WHO ORS solution (15%; odds ratio = 0.6, 95% confidence interval = 0.4–1.0). There was no significant difference in the incidence of hyponatremia (serum Na <130 mmol/L) at 24 hours between the 2 treatment groups (11% in reduced osmolarity ORS solution group vs 9% in the WHO ORS solution group; odds ratio = 1.3; 95% confidence interval = 0.8–2.2). The frequency of patients with serum Na <125 mmol/L at 24 hours was 13 of 341 (4%) in children who were treated with reduced osmolarity ORS solution versus 7 of 334 (2%) in children who received the WHO ORS solution.

Conclusions.

Treatment with reduced osmolarity ORS solution was associated with a 33% reduction in the need for unscheduled intravenous therapy and had no apparent effect on stool output and illness duration when compared with treatment with the standard WHO ORS solution. Children with acute diarrhea, therefore, may benefit from a reduced osmolarity ORS solution. The results of trials that examine the efficacy and safety of reduced osmolarity ORS solution in adult patients with cholera have to be taken into consideration before consensus on composition of oral rehydration formulation can be reached.
A Population-Based Study of Crashes Involving 16- and 17-Year-Old Drivers: The Potential Benefit of Graduated Driver Licensing Restrictions
Authors: Cvijanovich Natalie Z. , Cook Lawrence J. , Mann N. Clay , Dean J. Michael
Published: August 2004

Objective.

To evaluate the potential effectiveness of graduated driver licensing programs using population-based linked data for motor vehicle crashes (MVCs) that involved teenaged drivers (TDs).

Methods.

Utah crash, inpatient hospital discharge, and emergency department databases were analyzed and probabilistically linked. We computed hospital charges and compared violations, contributing factors, seatbelt use, and passengers for TDs (16–17 years old) relative to adult drivers (18–59 years old).

Results.

TDs comprised 5.8% of the study population, but were involved in 19.0% of MVCs. TD crashes resulted in $11 million in inpatient hospital charges and 158 fatalities. TD crashes were 1.70 times (95% confidence interval [CI]: 1.34, 2.04) less likely to result in fatal injury to drivers than were crashes that involved adult drivers, but TDs were 2.20 times (95% CI: 1.96, 2.47) more likely to receive citations. The following were findings of the study: 1) 11% of all TD crashes but 19% of fatal TD crashes occurred between 2200 and 0600 hours; 2) TDs used seatbelts less often than did adult drivers (79.1% vs 84.4%) and less often with passengers present (81.9% vs 75.0%; 3) TDs were 1.72 times (95% CI: 1.38, 2.14) more likely to be involved in crashes that resulted in seriously or fatally injured occupants when driving with passengers than when driving alone.

Conclusions.

TDs are overrepresented in MVCs. TD crashes have a higher fatality rate at night, and TDs wear seatbelts less often than do adult drivers. Passengers affect TD crash characteristics. Graduated driver licensing programs that target state-specific characteristics of TDs may decrease morbidity and mortality.
Bilirubin and Serial Auditory Brainstem Responses in Premature Infants
Authors: Amin Sanjiv B. , Ahlfors Charles , Orlando Mark S. , Dalzell Larry E. , Merle Kathleen S. , Guillet Ronnie
Published: August 2004

Objectives.

To determine the usefulness of the bilirubin-albumin (B:A) molar ratio (MR) and unbound bilirubin (UB) as compared with serum total bilirubin (TB) in predicting bilirubin encephalopathy as assessed by auditory brainstem responses (ABR) in infants of 28 to 32 weeks' gestational age.

Study Design.

During a 2-year period, serial ABRs were obtained on 143 infants of 28 to 32 weeks' gestational age during the first postnatal week. Waveforms were categorized on the basis of response replicability and the presence of waves III and V. Wave V latencies were also serially analyzed when measurable for individual infants. Maturation of the ABR was defined as abnormal when the waveform category worsened and/or latency increased during the study interval. Serum albumin was analyzed at 48 to 72 hours of age in all patients. Serum TB was analyzed as clinically indicated. Aliquots of the same samples were also analyzed for UB in a subset of infants.

Results.

The mean peak TB concentration (10.1 ± 1.7 mg/dL) for the 71 infants with normal ABR maturation was not significantly different from the mean peak TB (10.2 ± 2.1 mg/dL) in the 24-hour period preceding the ABR's first showing abnormal maturation in the other 55 infants. However, in infants with UB analyzed, the mean peak UB (0.62 ± 0.20 vs 0.40 ± 0.15 μg/dL) was significantly higher in the infants with abnormal maturation (n = 25) than in infants with normal maturation (n = 20). The B:A MR results were equivocal. In the entire study population, there was no difference in B:A MR between infants with normal versus abnormal ABR maturation. However, in the subset of infants in whom UB was measured, although TB was not different, there was a significant difference in B:A MR. Based on receiver-operating characteristic curves, a UB level of 0.5 μg/dL was the best discriminator with a sensitivity of 70% and a specificity of 75%. The proportion of infants who had UB >0.5 μg/dL and UB ≤0.5 μg/dL and who had abnormal ABR, maturation was 0.81 and 0.33, respectively, with a significant difference in the incidence of transient bilirubin encephalopathy among these 2 groups. The relative risk of abnormal ABR maturation with UB >0.5 μg/dL compared with UB ≤0.05 μg/dL was 2.45 (95% confidence interval: 1.33–4.49).

Conclusions.

UB is a more sensitive predictor than either serum bilirubin or B:A MR of abnormal ABR maturation, and hence transient bilirubin encephalopathy in premature newborns with hyperbilirubinemia.
Serotonin Transporter Gene Variation Is a Risk Factor for Sudden Infant Death Syndrome in the Japanese Population
Authors: Narita Naoko , Narita Masaaki , Takashima Sachio , Nakayama Masahiro , Nagai Toshiro , Okado Nobuo
Published: August 2004

Objective.

Serotonin (5-HT) in the nervous system is a major factor in facilitation of the brain center for respiration. Variations in the promoter region of the 5-HT transporter (5-HTT) gene have been shown to potentially regulate 5-HT activity in the brain. Therefore, we aimed to identify the possibility that specific allele variants of the 5-HTT gene can be found as a genetic background for sudden infant death syndrome (SIDS).

Methods.

Polymorphisms in the 5′ regulatory region of the 5-HTT gene were determined in genomic DNA obtained from 27 SIDS victims and 115 age-matched health control participants.

Results.

There were significant differences in genotype distribution and allele frequency of the 5-HTT promoter gene between SIDS victims and age-matched control participants. The L and XL alleles were more frequently found in SIDS victims than in age-matched control participants.

Conclusion.

Efficiency in the transportation of 5-HTT with the L allele is known to be higher than that with the S allele. The excitatory function by 5-HT is considered to be lower in the respiratory center of individuals with the L allele compared with those with S allele. The XL allele variant has shown another novel biological risk factor for SIDS.