bluuebunny/crossref_metadata_2025 huggingface dataset:
Declining Severity Adjusted Mortality: Evidence of Improving Neonatal Intensive Care
Authors: Richardson Douglas K. , Gray James E. , Gortmaker Steven L. , Goldmann Donald A. , Pursley DeWayne M. , McCormick Marie C.
Published: August 2004

Objectives.

Declines in neonatal mortality have been attributed to neonatal intensive care. An alternative to the “better care” hypothesis is the “better babies” hypothesis; ie, very low birth weight infants are delivered less ill and therefore have better survival.

Design.

We ascertained outcomes of all live births <1500 g in two prospective inception cohorts. We estimated mortality risk from birth weight and illness severity on admission and measured therapeutic intensity. We calculated logistic regression models to estimate the changing odds of mortality between cohorts.

Patients and Setting.

Two cohorts in the same two hospitals, 5 years apart (1989–1990 and 1994–1995) (totaln = 739).

Results.

Neonatal intensive care unit mortality declined from 17.1% to 9.5%, and total mortality declined from 31.6% to 18.4%. Cohort 2 had lower risk (higher birth weight, gestational age, and Apgar scores and lower admission illness severity for newborns ≥750 g). Risk-adjusted mortality declined (odds ratio, 0.52; confidence interval, 0.29–0.96). One third of the decline was attributable to “better babies” and two thirds to “better care.” Use of surfactant, mechanical ventilation, and pressors became more aggressive, but decreases in monitoring, procedures, and transfusions resulted in little change in therapeutic intensity.

Conclusions.

Mortality decreased nearly 50% for infants <1500 g in 5 years. One third of this decline is attributable to improved condition on admission that reflects improving obstetric and delivery room care. Two thirds of the decline is attributable to more effective newborn intensive care, which was associated with greater aggressiveness of respiratory and cardiovascular treatments. Attribution of improved birth weight specific mortality solely to neonatal intensive care may underestimate the contribution of high-risk obstetric care in providing “better babies.”
The Effect of Investigator Compliance (Observer Bias) on Calculated Efficacy in a Pertussis Vaccine Trial
Authors: Cherry James D. , Heininger Ulrich , Stehr Klemens , Christenson Peter
Published: August 2004

Background.

In the course of a large pertussis vaccine efficacy trial we realized that investigator compliance could have a major impact on calculated vaccine efficacy.

Design.

In our pertussis vaccine efficacy trial, the study investigators were to monitor illness in study families by telephone every 2 weeks. If a cough illness of ≥7 days duration was noted, the study child was to be evaluated. If the cough illness persisted for ≥14 days, the child was to be referred to a central investigator. For this report we analyzed study physician evaluation rates and rates of referral to the central investigators. Physician practices were separated into three compliance categories: high, intermediate, and low. We analyzed vaccine efficacy of an acellular pertussis component DTP vaccine (DTaP) and a whole cell pertussis component DTP vaccine (DTP) by compliance category. Bordetella pertussisinfection was documented by culture of the organism in the study child or in a household contact or by a significant antibody response to pertussis toxin determined by enzyme-linked immunosorbent assay.

Results.

Using a clinical case definition that included both mild and typical pertussis (cough illness ≥7 days duration) efficacy of DTaP vaccine was 40% (95% confidence interval [CI] = −3–65) in the high compliance category and 78% (95% CI = 65–86) and 75% (95% CI = 53–87) in the intermediate and low compliance groups, respectively. Similar, but less marked, differences in efficacy were noted with DTP vaccine recipients. Using a clinical case definition that required ≥21 days of cough with paroxysms, whoop, or vomiting (typical pertussis) the efficacy of DTaP vaccine was 69% (95% CI = 41–83) in the high compliance category and 86% (95% CI = 76–92) and 84% (95% CI = 64–93) in the intermediate and low compliance groups, respectively. In contrast, the efficacy of DTP vaccine did not vary by compliance category using this case definition. The attack rate in children vaccinated with diphtheria and tetanus toxoids vaccine (DT) was twofold less in low compliance physician practices when compared with the rates in high and intermediate groups. The DT/DTaP and DT/DTP fold-change differences were less in the high compliance group compared with the intermediate and low compliance groups.

Conclusions.

Our data suggest that observer compliance (observer bias), can significantly inflate calculated vaccine efficacy. It is likely that all recently completed efficacy trials have been effected by this type of observer bias and all vaccines have considerably less efficacy against mild disease than published data suggest.
Syncope Recurrence in Children: Relation to Tilt-test Results
Authors: Salim Mubadda A. , Ware Linda E. , Barnard Marie , Alpert Bruce S. , DiSessa Thomas G.
Published: August 2004

Objectives.

To examine the intermediate-term outcome of children with syncope and its relationship to tilt test.

Design.

This was a retrospective study of 45 children. In 20, the tilt test was negative. Follow-up with respect to the recurrence of syncope was obtained via chart review, a mailed questionnaire, or telephone interview.

Results.

Follow-up data were available on 15 children whose tilt test was negative and on all 25 tilt-test positive children. Recurrent syncope was significantly greater in the positive-tilt children (13 of 25) than the negative-tilt children (2 of 15). There was no difference between the syncope-free group and the recurrent syncope group or between the tilt-positive and tilt-negative groups with respect to age at initial syncope, duration of symptoms, age at tilt test, and duration of follow-up. Children with a positive tilt test and those with recurrent syncope had more syncopal episodes before their evaluation than either the group with a negative tilt test or the group with no recurrent syncope, respectively.

Conclusions.

Syncope may recur after either a negative or a positive tilt test. The recurrence rate, however, is higher for the tilt-positive children.
Clinically Significant Upper Gastrointestinal Bleeding Acquired in a Pediatric Intensive Care Unit: A Prospective Study
Authors: Chaı̈bou Mahamadou , Tucci Marisa , Dugas Marc-André , Farrell Catherine Ann , Proulx François , Lacroix Jacques
Published: August 2004

Objectives.

To determine the incidence, risk factors, and complications associated with or attributable to clinically significant upper gastrointestinal (GI) bleeding acquired in a pediatric intensive care unit (ICU).

Methods.

Prospective, descriptive epidemiologic study in a multidisciplinary pediatric ICU of a tertiary-care university hospital. Upper GI bleeding was considered to be present if hematemesis occurred or blood was present in the gastric tube. An upper GI bleed was qualified as clinically significant if two or three reviewers independently assessed that at least one of the six complications considered for analysis was attributable to the upper GI bleed.

Results.

A cohort of 1114 consecutive admissions was enrolled; 108 (9.7%) were excluded mostly (37.0%) because they already had an upper GI bleed at entry to the pediatric ICU. The final sample included 1006 admissions (881 patients); 103 upper GI bleeds (10.2%) were diagnosed, including 16 clinically significant upper GI bleeds (1.6%). Complications attributed to an upper GI bleed included: decreased hemoglobin concentration (10 cases), transfusion (10), hypotension (3), and surgery (1). Three independent risk factors for clinically significant upper GI bleeding were retained by multivariate analysis: respiratory failure, coagulopathy, and pediatric risk of mortality score ≥10. Nine of the 16 cases (56.3%) with clinically significant upper GI bleeding had three risk factors, 14 (87.5%) had two, and 1 (6.3%) had none.

Conclusions.

Clinically significant upper GI bleeds are rare in critically ill children. Prophylaxis to prevent them may be limited to patients who present with at least two risk factors.
Comparison of Fentanyl/Midazolam With Ketamine/Midazolam for Pediatric Orthopedic Emergencies
Authors: Kennedy Robert M. , Porter Fran L. , Miller J. Philip , Jaffe David M.
Published: August 2004

Objective.

Emergency management of pediatric fractures and dislocations requires effective analgesia, yet children's pain is often undertreated. We compared the safety and efficacy of fentanyl- versus ketamine- based protocols.

Methodology.

Patients 5 to 15 years of age needing emergency fracture or joint reduction (FR) were randomized to receive intravenous midazolam plus either fentanyl (F/M) or ketamine (K/M). Measures of efficacy were observational distress scores and self- and parental-report. Measures of safety were frequency of abnormalities in and need for support of cardiopulmonary function and other adverse effects.

Results.

During FR, K/M subjects (n = 130) had lower distress scores and parental ratings of pain and anxiety than did F/M subjects (n = 130). Although both regimens equally facilitated reductions, deep sedation, and procedural amnesia, orthopedists favored K/M. Recovery was 14 minutes longer for K/M.

Fewer K/M subjects had hypoxia (6% vs 25%), needed breathing cues (1% vs 12%), or required oxygen (10% vs 20%) than did F/M subjects. Two K/M subjects required assisted ventilation briefly. More K/M subjects vomited. Adverse emergence reactions were rare but equivalent between regimens.

Conclusions.

During emergency pediatric orthopedic procedures, K/M is more effective than F/M for pain and anxiety relief. Respiratory complications occurred less frequently with K/M, but respiratory support may be needed with either regimen. Both regimens facilitate reduction, produce amnesia, and rarely cause emergence delirium. Vomiting is more frequent and recovery more prolonged with K/M.
Pertussis Encephalopathy With High Cerebrospinal Fluid Antibody Titers to Pertussis Toxin and Filamentous Hemagglutinin
Authors: Grant Cameron C. , McKay E. John , Sci Dr Med , Simpson Alan , Buckley David
Published: August 2004

A 7-year-old unimmunized girl with pertussis presented with respiratory failure and electroencephalographic evidence of an encephalopathy. The cerebrospinal fluid (CSF)/serum ratio of antibodies to pertussis toxin and filamentous hemagglutinin were 11- and ninefold higher than the CSF/serum ratio of total immunoglobulin G. The CSF/serum ratio of albumin was normal. These findings indicate production of antibodies in the central nervous system to Bordetella pertussis antigens and imply, therefore, that the pertussis encephalopathy in this girl was associated with the entry of pertussis antigens into the central nervous system.
Detection ofMycobacterium tuberculosisin Gastric Aspirates Collected From Children: Hospitalization Is Not Necessary
Authors: Lobato Mark N. , Loeffler Ann M. , Furst Karen , Cole Barbara , Hopewell Philip C.
Published: August 2004

Objective.

To compare the yields of gastric aspirates collected for culture of Mycobacterium tuberculosis from children evaluated as outpatients versus inpatients and to determine factors associated with a positive culture.

Methods.

Retrospective study of 100 children <12 years of age with tuberculosis diagnosed at a pediatric referral hospital or in one of two tuberculosis control programs in California.

Results.

Of the 100 children who had tuberculosis, 80 had at least one gastric aspirate collected. M tuberculosis was isolated from 33 (41%) of the 80 children who had a gastric aspirate; 4 children had a positive culture from an aspirate subsequent to the first. Inpatients had a higher proportion of positive gastric aspirates than that of children who had aspirates collected as outpatients (48% vs 37%); however, this difference was not statistically significant. Resistance to isoniazid was found in three isolates (9%) of children all of whose presumptive source case had a susceptible strain ofM tuberculosis. Characteristics that were associated with an ∼50% yield from gastric aspirates were identification of a source case, age <2 years, birth in the United States, symptomatic tuberculosis, and pulmonary disease.

Conclusions.

The culture of M tuberculosisfrom gastric aspirates of children in the outpatient setting has a yield comparable to aspirates collected from hospitalized children. Collection of gastric aspirates in the outpatient setting will reduce both the cost and the inconvenience of the procedure. Although the yield from gastric aspirates is relatively low, important information including drug susceptibility patterns may be obtained. tuberculosis, gastric aspirate, children.
Limited Evaluation of Microscopic Hematuria in Pediatrics
Authors: Feld Leonard G. , Meyers Kevin E. C. , Kaplan Bernard S. , Stapleton F. Bruder
Published: August 2004

Objective.

The purpose was to determine the value of the standard laboratory and radiologic evaluation of microscopic hematuria in children, and to determine the prevalence of idiopathic hypercalciuria in those children referred for evaluation of unexplained microscopic hematuria.

Methods.

This was a retrospective study of 325 children referred from 1985 to 1994 for the evaluation of asymptomatic microscopic hematuria. The diagnostic studies reviewed included serum creatinine, blood urea nitrogen, serum electrolyte studies, serum complement concentration, antinuclear antibody, urinalysis, urine calcium to creatinine ratios, urinary protein to creatinine ratio and/or 24-hour urinary protein excretion, renal ultrasounds, intravenous pyelograms, voiding cystourethrograms, and historical information.

Results.

All creatinine and electrolyte values were normal for age, and none of the biochemical tests obtained in the children with hypercalciuria was abnormal. Of the 325 patients with idiopathic microscopic hematuria, only 18 had abnormal renal ultrasound examinations and 9 voiding cystourethrograms showed low-grade reflux. Hypercalciuria was found in 29 patients. The family history was positive for urolithiasis in 16% of patients without hypercalciuria compared with 14% of patients with hypercalciuria. A positive family history of hematuria was reported in 25% of patients; 62 patients did not have hypercalciuria and 4 of the patients had hypercalciuria. Microscopic hematuria in children is a benign finding in the vast majority of children.

Conclusions.

Our data demonstrate that a renal ultrasound, voiding cystourethrogram, cystoscopy, and renal biopsy are not indicated in the work-up of microscopic hematuria, and microhematuria in the otherwise healthy child is a minimal health threat, rarely indicative of serious illness.
Language of Early- and Later-identified Children With Hearing Loss
Authors: Yoshinaga-Itano Christine , Sedey Allison L. , Coulter Diane K. , Mehl Albert L.
Published: August 2004

Objective.

To compare the language abilities of earlier- and later-identified deaf and hard-of-hearing children.

Method.

We compared the receptive and expressive language abilities of 72 deaf or hard-of-hearing children whose hearing losses were identified by 6 months of age with 78 children whose hearing losses were identified after the age of 6 months. All of the children received early intervention services within an average of 2 months after identification. The participants' receptive and expressive language abilities were measured using the Minnesota Child Development Inventory.

Results.

Children whose hearing losses were identified by 6 months of age demonstrated significantly better language scores than children identified after 6 months of age. For children with normal cognitive abilities, this language advantage was found across all test ages, communication modes, degrees of hearing loss, and socioeconomic strata. It also was independent of gender, minority status, and the presence or absence of additional disabilities.

Conclusions.

Significantly better language development was associated with early identification of hearing loss and early intervention. There was no significant difference between the earlier- and later-identified groups on several variables frequently associated with language ability in deaf and hard-of-hearing children. Thus, the variable on which the two groups differed (age of identification and intervention) must be considered a potential explanation for the language advantage documented in the earlier-identified group.
Central Nervous System Tuberculosis in Children: A Review of 214 Cases
Authors: Yaramiş Ahmet , Gurkan Fuat , Elevli Murat , Söker Murat , Haspolat Kenan , Kirbaş Gökhan , Taş M. Ali
Published: August 2004

Objective.

To study the clinical, laboratory, and treatment features observed in pediatric patients with tuberculous meningitis in Turkey.

Study Design.

Retrospective case review study.

Methods.

Review of medical records for demographic data, medical history, clinical manifestations, auxiliary test results, complications, and treatment of 214 children with central nervous system tuberculosis (TB) admitted to Dicle University's hospital between August 1988 and February 1996.

Results.

Of the 214 patients with tuberculous meningitis, 112 (52%) were male. The mean age at presentation was 4.1 years, with 165 patients (77%) younger than 5 years. Twenty-two patients (10%) were in the first stage of the disease, 120 (56%) in the second, and 72 (34%) in the third. Our epidemiologic data showed that 141 (66%) of the patients had a family history of TB, and 64 (30%) had a Mantoux skin test result of >10 mm of induration. Radiographic studies demonstrated abnormal chest findings in 187 patients (87%) (hilar adenopathy, 33%; infiltrates, 33%; miliary pattern, 20%; and pleural effusions, 1%, and 172 (80%) cases with hydrocephalus, 26% with parenchymal disease, 15% with basilar meningitis, and 2% with tuberculomas. Only 22 (13%) of 164 children had a positive acid-fast bacilli smear in cerebrospinal fluid, andMycobacterium tuberculosis was isolated in 49 patients (30%). All the patients were treated with Isoniazid, rifampin, and streptomycin or pyrazinamide for 2 months, followed by 10 months of Isoniazid and rifampin alone. Also, all the patients received adjuvant treatment with steroids early in the course of treatment, and 140 of 172 cases with hydrocephalus had surgical intervention. The overall mortality rate was 23%.

Conclusion.

One or more of these findings: a family history of TB, positive tuberculin skin test results, abnormal cranial computed tomography, and/or cerebrospinal fluid analysis compatible with TBM were found in all but 3 children in our study. central nervous system, tuberculous meningitis, diagnosis, hydrocephalus, children.
National Trends in the Management of Cardiovascular Disease Risk Factors in Children: Second NHLBI Survey of Primary Care Physicians
Authors: Kimm Sue Y. S. , Payne Gerald H. , Stylianou Mario P. , Waclawiw Myron A. , Lichtenstein Carolyn
Published: August 2004

Background.

The evidence that atherosclerosis begins during adolescence has led to the belief that primary prevention of cardiovascular disease (CHD) should commence in childhood. Although several national guidelines have been issued for the detection and treatment of CHD risk factors in children, concerns continue to be expressed regarding what constitutes appropriate measures and when to institute such measures in children. A 1988 national survey of primary care physicians revealed variation in the management of CHD risk factors in children by physician categories, which suggested the underlying quandary among physicians regarding CHD risk factors in children.

Objective.

To assess current clinical management of pediatric CHD risk factors in the primary care setting and also to evaluate time trends between the current and 1988 surveys.

Methods.

A 25-minute telephone survey was conducted with 1036 of eligible physicians (ie, >20 hours per week direct patient care including at least five pediatric patient contacts) selected from a national probability sample in three practice categories (family practitioners, pediatricians, and general practitioners). The questionnaire assessed the current practice of these physicians in the primary care setting regarding cholesterol and blood pressure (BP) screening and treatment, both nonpharmacologic and pharmacologic, and physician attitude and knowledge.

Results.

Cholesterol screening in children was performed by 75.7% of all physicians. Nonscreening was highest among general practitioners (38%) and lowest among pediatricians (12%). BP was measured by almost all physicians. The majority of physicians (71%) prescribed diet as the first cholesterol-lowering step, but ∼16% also used pharmacologic therapy. Cholesterol synthesis inhibitors and bile acid sequestrants were the drugs used most commonly. Approximately 25% of physicians have used drugs in children to treat high BP. Diuretics and β-blockers were used most frequently. More than one fourth of the physicians had some concern about identifying and treating children for CHD risk factors. There was slightly less cholesterol measurement in 1995 compared with 1988, and no notable increase in the knowledge regarding major CHD risk factors.

Conclusion.

The results of the second National Heart, Lung, and Blood Institute survey of primary care physicians suggest that additional inroads need to be made in the dissemination of the national guidelines for the management of CHD risk factors in children, including appropriate use of pharmacologic agents.
Exposure to and Compliance With Pediatric Injury Prevention Counseling—United States, 1994
Authors: Quinlan Kyran P. , Sacks Jeffrey J. , Kresnow Marcie-jo
Published: August 2004

Background.

Because injuries are the leading cause of death in children, injury prevention counseling is recommended as part of routine pediatric care. Increasing such counseling is a national health objective. Estimating the proportion of US children who receive such counseling and assessing their compliance with safety recommendations may help improve counseling efforts.

Methods.

Respondents to a 1994 random digit-dial telephone survey of the US population were asked about receipt of age-appropriate injury prevention counseling at a medical visit and related safety practices for a randomly selected child 0 to 14 years of age in the household (N = 1596).

Results.

Receiving any injury prevention counseling was reported for 39.3% of children 0 to 14 years old who had a medical visit in the past year and was more common among children who were younger, lived in urban areas, and lived in poverty. In general, receiving counseling was associated with safer behaviors. Counseling about ipecac was reported for 17.2% of children 0 to 6 years old; having ipecac in the home was more likely for those counseled (73.4% vs 32.0%). Counseling about posting the poison control number was reported for 24.9% of children 0 to 6 years old; posting this number was more common among those counseled (79.3% vs 52.6%). Counseling about bicycle helmets was reported for 18.6% of children 5 to 14 years old; a report of always wearing a helmet was more common among those counseled (43.9% vs 19.1%). Counseling about car seats and safety belts was reported for 25.4% of children 0 to 14 years old; a report of always using occupant restraints was more common among those counseled (89.0% vs 78.2%).

Conclusions.

Injury prevention counseling is associated with reported preventive safety practices among US children, but a relatively small proportion of households with young children report receiving such counseling. Health care providers should increase efforts to provide injury prevention counseling. counseling, wounds and injuries, child, accident prevention.
Dad, May I Have the Keys? Factors Influencing Which Vehicles Teenagers Drive
Authors: Rivara Frederick P. , Rivara Matthew B. , Bartol Keith
Published: August 2004

Objective.

To determine the role of vehicle safety features, particularly vehicle size and weight, compared with other factors in parental decisions about choosing vehicles for teens to drive.

Methods.

Written questionnaire to parents of teenagers attending drivers education training.

Results.

The response rate to the survey was 62.6%. Two thirds reported that the teen would drive an existing family vehicle, 10.5% would buy an additional vehicle, and 20.3% would buy another vehicle as well as have the teen drive an existing family vehicle. Large size was important to only ∼40% of families purchasing a car for the teen or families in which the teen would use an existing family vehicle. Gas mileage and other safety features were ranked as more important even in families in which a large car was available in the household.

Conclusions.

Families did not rank vehicle size and weight as important as other, less effective safety features in choosing cars for their teens. Information about vehicle crash-worthiness should be incorporated into drivers education and other programs reaching new teen drivers and their families.
Reduction of Cardiovascular Disease: What Is the Role of the Pediatrician?
Authors: Sinaiko Alan R. , Prineas Ronald J.
Published: August 2004

It is apparent from the results of the 1995 and 1998 surveys reported by Kimm et al in this issue of Pediatricsthat pediatricians are interested in blood pressure and lipids but uncertain about the management of these coronary heart disease (CHD) risk factors. Data from longitudinal epidemiologic studies initiated in pediatric cohorts support the important role for pediatricians in the detection of children at risk for CHD, and detection should be followed by effective intervention/treatment programs. However, the latter may be difficult in most office practices, because of the intensive effort by specialized personnel required to successfully reduce CHD risk.
Otoacoustic Emissions as a Screening Test for Hearing Impairment in Children Recovering From Acute Bacterial Meningitis
Authors: Richardson Martin P. , Williamson Timothy J. , Reid Andrew , Tarlow Michael J. , Rudd Peter T.
Published: August 2004

Objectives.

To study the efficacy of otoacoustic emissions (OAEs) as a screening test for hearing impairment in children with acute bacterial meningitis. Hearing tests were performed before discharge from the hospital in an attempt to improve coverage and avoid delays in the diagnosis of postmeningitic hearing loss.

Methods.

Children with bacterial meningitis were recruited from 21 centers. In the 48 hours before discharge from the hospital, all patients underwent a thorough audiologic assessment consisting of transient evoked OAEs, auditory brainstem responses (ABRs), otoscopy, and tympanometry. Hearing loss was defined as ABR threshold ≥30 dB. The results of OAE screening were compared with the gold standard of ABR threshold.

Results.

Of 124 children recruited, we were able to perform both OAEs and ABRs on 110 children. Seven (6.3%) of the 110 children had ABR threshold ≥30 dB; 2 had sensorineural hearing loss and 5 had conductive hearing loss. At follow-up, hearing loss persisted in both cases of sensorineural hearing loss and no new cases were identified. All 7 children with hearing loss failed the OAE screening test. Ninety-four children with normal hearing thresholds passed the test, and 9 failed. Thus, the screening test had a sensitivity of 1.00 (95% confidence interval, 0.59 to 1.00), a specificity of 0.91 (0.85 to 0.97), a positive predictive value of 0.44 (0.20 to 0.70), and a negative predictive value of 1.00 (0.96 to 1.00).

Conclusions.

OAE screening in children recovering from meningitis was found to be feasible and effective. The test was highly sensitive and reasonably specific. Inpatient OAE screening should allow early diagnosis of postmeningitic hearing loss and prompt auditory rehabilitation.
Pediatric Pneumococcal Bone and Joint Infections
Authors: Bradley John S. , Kaplan Sheldon L. , Tan Tina Q. , Barson William J. , Arditi Moshe , Schutze Gordon E. , Wald Ellen R. , Givner Laurence B. , Mason Edward O. ,   The Pediatric Multicenter Pneumococcal Surveillance Study Group (PMPSSG)
Published: August 2004

Objective.

To describe the clinical and microbiological characteristics of infants and children with bone and joint infections caused by penicillin-susceptible and penicillin-nonsusceptible strains of Streptococcus pneumoniae.

Design.

Multicenter, prospective patient accrual; retrospective chart review of identified patients.

Setting.

Eight children's hospitals in the United States.

Participants.

Forty-two children with bone and/or joint infections prospectively enrolled in the United States Pediatric Multicenter Pneumococcal Surveillance Study from September 1, 1993 to August 31, 1996.

Outcome Measures.

Data were collected on multiple variables, including age, gender, race, days of symptoms before and during hospitalization, antibiotic and surgical therapy, laboratory and imaging studies.

Results.

Of the 42 children enrolled (21 bone, 21 joint infections), 14 had isolates that were not susceptible to penicillin. Eight of 16 (50%) strains isolated from children who received antibiotics within 4 weeks before hospitalization were not susceptible to penicillin, compared with 4 of 15 (27%) strains isolated from children without previous antibiotic exposure. Clinical response to therapy was similar between children infected by penicillin-susceptible strains compared with those infected by penicillin-nonsusceptible strains, including duration of hospitalization (9.1 days vs 11.2 days), days of intravenous antibiotic therapy (25.3 days vs 24.6 days), days of fever (3.6 days vs 3.1 days), and sequelae (14% vs 7%). The most commonly prescribed single agents for parenteral therapy in definitive treatment were ceftriaxone (36%), penicillin (15%), and clindamycin (15%). Oral therapy followed parenteral therapy in 56% of children. The mean (± standard deviation) duration of total antibiotic therapy in children with osteomyelitis was 57.5 ± 48.6 days (range, 23–196 days) and 29.2 ± 11.8 days (range, 12–67 days) for arthritis. Late sequelae (long-term destructive changes of the bone or joint) were documented in 5 (12%) children, 4 with osteomyelitis, and 1 with arthritis. Sequelae occurred in 30% of children with long bone osteomyelitis associated with infection in the adjacent joint. The age of children with sequelae was younger than those without sequelae (6.4 months vs 18.6 months).

Conclusions.

The demographic characteristics and anatomic sites of infection in our patients were similar to previously published series collected from single institutions before the emergence of significant antibiotic resistance in S pneumoniae. Our analysis suggests that children infected by penicillin-nonsusceptible strains have a similar clinical response to therapy when compared with children infected by penicillin-susceptible strains.
Procalcitonin Is a Marker of Severity of Renal Lesions in Pyelonephritis
Authors: Benador Nadine , Siegrist Claire-Anne , Gendrel Dominique , Greder Catherine , Benador Daivy , Assicot Marcel , Bohuon Claude , Girardin Eric
Published: August 2004

Objective.

In an attempt to differentiate acute pyelonephritis from lower urinary tract infection (UTI), we measured serum procalcitonin levels, a recently described marker of infection. We compared it with other commonly used inflammatory markers and evaluated its ability to predict renal involvement as assessed by dimercaptosuccinic acid (DMSA) scintigraphy.

Methods.

Serum C-reactive protein, leukocyte counts, and procalcitonin levels were measured in 80 children, 1 month to 16 years of age, admitted for suspected pyelonephritis. Renal involvement was assessed by 99mTe-DMSA scintigraphy in the first 5 days after admission. The examination was repeated at least 3 months later if the first result was abnormal.

Results.

In lower UTI, the mean procalcitonin (PCT) was 0.38 μg/L ± 0.19 compared with 5.37 μg/L ± 1.9 in pyelonephritis. In these two groups, respectively, leukocyte counts were 10939/mm3 ± 834 and 17429/mm3 ± 994, and C-reactive protein (CRP) levels were 30.3 mg/L ± 7.6 and 120.8 mg/L ± 8.9. When inflammatory markers were correlated to the severity of the renal lesion as ranked by DMSA scintigraphy, we found a highly significant correlation with plasma levels of PCT, but borderline significance with CRP and none with leukocyte counts. Patients without vesicoureteral reflux had a mean PCT of 5.16 μg/L ± 2.33, which was not significantly different from that in patients with reflux who had a mean PCT of 5.76 μg/L ± 3.49. For the prediction of renal lesions at admission, CRP had a sensitivity of 100% and a specificity of 26.1%. The sensitivity and specificity of PCT were 70.3% and 82.6%, respectively.

Conclusion.

We conclude that serum PCT levels were increased significantly in children with febrile UTI when renal parenchymal involvement (assessed by DMSA scintigraphy) was present and allowed for prediction of patients at risk of severe renal lesions.
Lower Extremity Compartment Syndrome Resulting From a Toddler's Bed
Authors: Haasbeek Jeffrey F.
Published: August 2004

This report recounts an unusual case of compartment syndrome of the leg and foot resulting from hanging on the side of a toddler's bed in a 1½-year-old boy. Parents apparently found the patient on the side of the bed in the morning. Presentation to hospital revealed obvious tense compartments of the leg and foot. Intraoperative pressures were >100 mm Hg. Complete fasciotomies with secondary closure and skin grafting were performed. An ankle–foot orthrosis was used to prevent progression of ankle equinus. Jobst pressure garments were used to prevent hypertrophic scarring. One-year follow-up showed normal gait, function, and joint range of motion. Social services were consulted and the US Consumer Product Safety Commission was notified. As pediatric physicians, we need to be aware of possible and potential hazards in the child's environment. This case represents a unique case of compartment syndrome related to persistent limb elevation and compression.
Prevention of Rotavirus Disease: Guidelines for Use of Rotavirus Vaccine
Authors:   Committee on Infectious Diseases
Published: August 2004

Virtually all children experience rotavirus (Rv) infection before school entry. In the United States and other temperate countries, Rv disease peaks in the winter and during this time is responsible for the majority of episodes of diarrhea in infants and young children.1–4 Data collected by the Centers for Disease Control and Prevention from 1979 through 1992 indicate that approximately 50 000 hospitalizations attributable to Rv occur annually in the United States, a number that approximates about 1 in 78 children being hospitalized with Rv diarrhea by 5 years of age.2,5

RotaShield (Wyeth-Lederle Vaccines and Pediatrics, Philadelphia, PA) was licensed by the Food and Drug Administration on August 31, 1998, for oral administration to infants at 2, 4, and 6 months of age. The rationale for using Rv immunization for prevention or modification of Rv disease is based on several considerations. First, the rate of illness attributable to Rv among children is comparable in industrialized and developing countries, which indicates that improved public sanitation is unlikely to decrease the incidence of disease.6,7 Second, although implementation of oral rehydration programs to prevent dehydration has improved in the United States, widespread use is inadequate to prevent significant morbidity.8–11 Third, trials of rhesus rotavirus-tetravalent (Rv) vaccine in the United States, Finland, and Venezuela show efficacy rates of approximately 80% for prevention of severe illness and 48% to 68% against Rv-induced diarrheal episodes.12–16 These results are similar to the protection observed after natural Rv infection, which also confers better protection against subsequent episodes of severe disease than against mild illness.17–19 This statement provides recommendations regarding the use of Rv vaccine in infants in the United States.
Cardiac Sequelae in Recurrent Cases of Kawasaki Disease: A Comparison Between the Initial Episode of the Disease and a Recurrence in the Same Patients
Authors: Nakamura Yosikazu , Oki Izumi , Tanihara Shinichi , Ojima Toshiyuki , Yanagawa Hiroshi
Published: August 2004

Objective.

Cardiac sequelae develop more frequently after recurrent Kawasaki disease than from the initial onset of the disease. The purpose of this study was to observe the existence of the sequelae at the initial and second onsets of the disease simultaneously with a large cohort.

Materials and Methods.

From the database of patients with Kawasaki disease prepared by the Japanese Kawasaki Disease Research Committee, 559 cases with recurrences recorded between 1989 through 1994 and their initial occurrence listed in the database were selected. Their proportions of cardiac sequelae after the initial and second onsets of Kawasaki disease were compared.

Results.

Of the 68 patients with cardiac sequelae after the initial onset, 32 (47%) suffered the sequelae after the second onset, whereas 78 (16%) of the 491 who were without cardiac sequelae after the initial onset developed the sequelae after the recurrence. Both proportions were higher than proportions in all patients with Kawasaki disease. In addition to the sex (male) and the existence of the sequelae after the initial onset, age at the second onset (older age) and the interval between the two episodes (longer period) were suspected to be risk factors for sequelae attributable to recurrent Kawasaki disease.

Conclusion.

Linked data of the initial and second episodes of Kawasaki disease showed that the risk of developing cardiac sequelae attributable to recurrent Kawasaki disease is high among both those with and without the sequelae at the initial episode. mucocutaneous lymph node syndrome, recurrence, cardiac sequelae, risk factors.
Involution Rate of Multicystic Renal Dysplasia
Authors: Kessler Oded J. , Ziv Niza , Livne Pinchas M. , Merlob P.
Published: August 2004

Objective.

To document the involution rate and long-term results of management of multicystic dysplastic kidney.

Materials and Methods.

Data were collected retrospectively for all 23 infants (16 boys) with multicystic dysplastic kidney who were treated at our center over the last 19 years (1977–1995). The diagnosis was based on prenatal ultrasound in 18 patients and on palpable abdominal mass in 5, and confirmed in all patients by postnatal ultrasound and radioisotope scan. Voiding cystography was performed in 18 patients to exclude vesicoureteral reflux. Mean follow-up was 46 months (range, 3 months to 5 years) and included serum creatinine measurements and renal ultrasonography.

Results.

Two groups of patients were identified. Ten (43.6%) with other urologic abnormalities (group A) and 13 patients without other urologic abnormalities (group B). Vesicoureteral reflux was observed in 4 patients. Nephrectomy was performed in 4 patients, all from group B. The other 19 patients were treated conservatively. Complete involution was observed in 8 patients in group A and 6 in group B after a mean follow-up period of 9.2 and 10 months, respectively. Two patients, 1 from each group, later underwent nephrectomy not because of no involution but because of an increase in the size of the kidney involved.

Conclusion.

Patients with multicystic renal dysplasia have significant associated urologic malformations, and the natural history of the disease is unpredictable. All patients require appropriate investigation of the urinary tract and long-term follow-up.

The most outstanding finding of the study is the much higher involution rate of multicystic renal dysplasia and the rate of associated urologic abnormalities than that reported in the literature. Surgery remains an option for the patients in the absence of no involution. multicystic dysplastic kidney, surgery, conservative.
Control of Severe Hyperbilirubinemia in Full-term Newborns With the Inhibitor of Bilirubin Production Sn-Mesoporphyrin
Authors: Martinez Jorge C. , Garcia Horacio O. , Otheguy Lydia E. , Drummond George S. , Kappas Attallah
Published: August 2004

Objective.

To assess the efficacy of Sn-mesoporphyrin (SnMP), a potent inhibitor of bilirubin production, in: a) moderating the need for phototherapy (PT) in full-term breastfed infants with plasma bilirubin concentrations (PBC) of ≥256.5 μmol/L and ≤307.8 μmol/L (≥15 mg/dL and ≤18 mg/dL, respectively) that were reached between ≥48 and ≤96 hours of age; b) diminishing the time required for the PBC to decline to ≤222.3 μmol/L (≤13 mg/dL) (closure of the case); c) decreasing the number of bilirubin determinations required for monitoring hyperbilirubinemia.

Study Participants.

Healthy full-term breastfed infants with a PBC between ≥256.5 μmol/L and ≤307.8 μmol/L (≥15 mg/dL and ≤18 mg/dL, respectively) reached between 48 to 96 hours of age.

Design/Methods.

After obtaining informed consent from the parents, infants were randomized to either the SnMP (6.0 μmol/kg birth weight, single dose, intramuscular) group or the control group. The infants' PBCs were followed by daily measurements either in the hospital or at discharge as outpatients until the hyperbilirubinemia had subsided (PBC ≤222.3 μmol/L [13mg/dL]). The total number of newborns enrolled in the study was 84; the SnMP group comprised 40 infants; the control group comprised 44 infants. The groups were similar in sex ratio, birth weight, gestational age, PBC, and age at enrollment. All infants were breastfed. Phototherapy was initiated at a PBC of 333.5 μmol/dL (19.5 mg/dL).

Results.

SnMP entirely eliminated the need for supplemental PT to control hyperbilirubinemia; in contrast, of the 44 control infants, 12 required treatment with PT (27%) when their PBC reached or exceeded the level (333.5 μmol/dL; 19.5 mg/dL) at which time the use of PT was dictated by hospital guidelines. None of the 40 SnMP-treated infants reached a PBC of 19.5 mg/dL. SnMP also markedly diminished the median hours to case closure (SnMP: median, 86.5 hours; minimum/maximum, 24/216 hours; controls: median, 120 hours; minimum/maximum, 72/336 hours); and significantly reduced the number of bilirubin determinations required for clinical monitoring of the infants (SnMP: median, 3; minimum/maximum, 1/9; controls: median, 5; minimum/maximum, 3/11). No adverse effects of SnMP use were observed.

Conclusion.

A single dose of SnMP proved effective in controlling severe hyperbilirubinemia in full-term breastfed newborns with high bilirubin levels between 48 and 96 hours. In addition, SnMP eliminated the need for PT and reduced the use of medical resources in the clinical treatment of this problem as well as the related, important and painful, emotional costs for both mothers and infants.
Evaluation of Risk Assessment Questions Used to Target Blood Lead Screening in Illinois
Authors: Binns Helen J. , LeBailly Susan A. , Fingar Ann R. , Saunders Stephen
Published: August 2004

Objective.

Beginning in 1995, Illinois law permitted targeted—as opposed to universal—blood lead screening in low-risk areas, which were defined by ZIP code characteristics. State guidelines recommended specific lead risk assessment questions to use when targeting screening. This study was designed to evaluate the sensitivity and specificity of Illinois lead risk assessment questions.

Design.

Parents bringing their 9- or 10- or 12-month and 24-month-old children for health supervision visits at 13 pediatric practices and parents of children (aged 6 through 25 months and who needed a blood lead test) receiving care at 5 local health departments completed a lead risk assessment questionnaire concerning their child. Children had venous or capillary blood lead testing. Venous confirmation results of children with a capillary level ≥10 μg/dL were used in analyses.

Children.

There were 460 children with both blood and questionnaire data recruited at the pediatric practices (58% of eligible) and 285 children (51% of eligible) recruited at local health departments. Of the 745 children studied, 738 provided a ZIP code that allowed their residence to be categorized as in a low-risk (n = 456) or high-risk (n = 282) area.

Results.

Sixteen children (3.5%) living in low-risk areas versus 34 children (12.1%) living in high-risk areas had a venous blood lead level (BLL) ≥10 μg/dL; 1.8% and 5.3%, respectively, had a venous BLL ≥15 μg/dL. For children living in low-risk areas, Illinois mandated risk assessment questions (concerning ever resided in home built before 1960, exposure to renovation, and exposure to adult with a job or hobby involving lead) had a combined sensitivity of .75 for levels ≥10 μg/dL and .88 for levels ≥15 μg/dL; specificity was .39 and .39, respectively. The sensitivity of these questions was similar among children from high-risk areas; specificity decreased to .27 and .28, for BLLs ≥10 μg/dL and ≥15 μg/dL, respectively. The combination of items requiring respondents to list house age (built before 1950 considered high risk) and indicate exposure to renovation had a sensitivity among children from low-risk areas of .62 for BLLs ≥10 μg/dL with specificity of .57; sensitivity and specificity among high-risk area children were .82 and .36, respectively. For this strategy, similar sensitivities and specificities for low and high-risk areas were found for BLLs ≥15 μg/dL.

Conclusions.

The Illinois lead risk assessment questions identified most children with an elevated BLL. Using these questions, the majority of Illinois children in low-risk areas will continue to need a blood lead test. This first example of a statewide screening strategy using ZIP code risk designation and risk assessment questions will need further refinement to limit numbers of children tested. In the interim, this strategy is a logical next step after universal screening.
A STD/HIV Prevention Trial Among Adolescents in Managed Care
Authors: Boekeloo Bradley O. , Schamus Lisa A. , Simmens Samuel J. , Cheng Tina L. , O'Connor Kathleen , D'Angelo Lawrence J.
Published: August 2004

Objective.

To determine if sexually transmitted diseases (STDs), including human immunodeficiency virus (HIV) infection, risk assessment, and education tools provided as part of office-based primary care reduce adolescent risky sexual behaviors.

Design.

A randomized intervention trial with 3- and 9-month follow-up.

Setting.

Five staff-model managed care sites in Washington, DC (n = 19 pediatricians).

Patients.

Consecutive 12- to 15-year-olds receiving a general health examination; 81% minority. Participation rate = 215/432 (50%). Nine-month follow-up rate = 197/215 (92%).

Intervention.

Audiotaped STD risk assessment and education about staying safe (safer = condoms, safest = abstinence).

Main Outcome Measures.

Adolescent-reported sexual intercourse and condom use.

Results.

More intervention adolescents reported pediatrician discussion on 11/13 sexual topics. Although more vaginal intercourse (odds ratio [OR] = 2.46, 95% confidence interval [CI] = 1.04–5.84) was reported in the intervention group at 3 months, this was not true of overall sexual intercourse (OR = 1.55, 95% CI = .73–3.32). More sexually active adolescents reported condom use in the intervention group at 3 months (OR = 18.05, 95% CI = 1.27–256.03). At 9 months, there were no group differences in sexual behaviors; however, more signs of STD were reported by the control (7/103) than the intervention group (0/94).

Conclusions.

STD risk assessment and education tools administered in a single office visit facilitated STD/HIV prevention education. Any impact on sexual activity and condom use was short-lived. Further research is needed to develop brief, office-based sexual risk reduction for young adolescents.