bluuebunny/crossref_metadata_2025 huggingface dataset:
Optimierungsbasierte Regelung des Hashimoto-SMB-ProzessesOptimizing Control of the Hashimoto SMB Process
Authors: Küpper Achim , Engell Sebastian
Published: June 2009

Simulierte Gegenstromprozesse (SMB-Prozesse) sind leistungsfähige chromatographische Trennverfahren, bei denen die physikalischen Eingangsgrößen (Zufluss- und Abflussströme) periodisch von einer Trennsäule zur nächsten geschaltet werden, sodass sich ein effektiver Gegenstrom von Feststoff und Flüssigkeit ergibt. Der sog. Hashimoto-Prozess integriert chemische Reaktoren in diesen Prozess, deren Position sich aber relativ zu den Zuflüssen nicht ändert. SMB-Trennprozesse und insbesondere Prozesse mit zusätzlichen Reaktoren zeigen ein komplexes nichtlineares Verhalten. In diesem Beitrag wird eine direkt optimierende prädiktive Regelung vorgestellt, die auf der Grundlage eines rigorosen, nichtlinearen Prozessmodells hoher Ordnung unter Einbeziehung aller Freiheitsgrade des Prozesses (Flussraten und Taktzeit) online den Lösungsmittelverbrauch minimiert und gleichzeitig die Produktreinheit und die gewünschte Ausbeute einhält. Es wird gezeigt, dass der Einfluss von Modellfehlern zu einem unbefriedigenden Regelverhalten führen kann und es wird eine Modifikation der Formulierung der Regelaufgabe vorgestellt, die zu einem robusten Verhalten führt. Das Regelungskonzept wird anhand von Simulationen und experimentellen Ergebnissen für die Razemisierung von Trögerscher Base verifiziert.
Flatness-Based Control Design for an Adaptive Belt Load LimiterFlachheitsbasierte Regelung eines adaptiven Gurtkraftbegrenzers
Authors: Seichter Dennis , Man Ho Lok , Fox Joachim
Published: June 2009

This paper presents the design of a flatness-based control principle for an adaptive load limiting restraint system developed by Continental. Differential flatness is a property found in certain nonlinear, time-invariant multivariable systems which allows effective model-based open loop control, as it facilitates the calculation of the inputs corresponding to a desired output trajectory. The paper focuses on modeling the system consisting of a drop tower test bench and the load limiter itself. After proving that the model is flat, the controller is designed. The comparison of simulation and experimental results shows the correctness of the model and a good performance of the controller. Thus the feasibilty of the flatness based control approach is shown for the application in this mechatronic passenger restraint system.
Vergleich der Anwendbarkeit von UML und UML-PA in der anlagennahen Softwareentwicklung der AutomatisierungstechnikEvaluation of UML and UML-PA for Software Engineering in Plant Automation
Authors: Katzke Uwe , Vogel-Heuser Birgit
Published: June 2009

Bei dem Entwurf von neuen Modellierungssprachen wird viel Wert darauf gelegt, möglichst jeden denkbaren Sachverhalt einer Domäne durch die Semantik der sprachlichen Mittel ausdrücken zu können, um den Anwendern die für die Domäne erforderlichen Sprachmittel zur Verfügung zu stellen und sie somit beim Systementwurf zu unterstützen. In dem Beitrag wird der Umgang von Anwendern mit der UML als “General Purpose Language” und mit der UML-PA als reduzierte Sprache für den Softwareentwurf der Automatisierungstechnik experimentell untersucht, um eine Aussage über die Eignung dieser Modellierungssprachen treffen zu können.
Actinide and lanthanide speciation in imidazolium-based ionic liquids
Authors: Billard Isabelle , Gaillard C.
Published: June 2009

The surprising speciation of actinides and lanthanides in ionic liquids (ILs) is reviewed, based on both experimental and theoretical studies. The unusual nature of ILs is shown to induce unique solvation, complexation and extraction features. The effect of water is also detailed.
An Unexpected Alliance: Stella Atwood, the California Clubwomen, John Collier, and the Indians of the Southwest, 1917–1934
Authors: Huebner Karin L.
Published: June 2009

During the 1920s and 1930s, women's clubs in California and throughout the nation took up the cause of Indian reform. These clubwomen brought national attention to the conditions and repressive policies under which Indian peoples across the country lived. In alliance with John Collier and Pueblo Indians, California clubwomen waged effective political campaigns, agitating for Indian religious freedom, the protection of tribal lands, and Native self-determination. Commissioner of Indian Affairs under Franklin Delano Roosevelt, Collier has long been considered the major architect of reformist policies with regard to Indians, yet the clubwomen were the primary individuals motivating him to take up Indian reform. The unexpected alliance forged between John Collier, the clubwomen, and Native Americans was the effective force that brought Indian reform to the nation.
"From Time Immemorial": The Fish-in Movement and the Rise of Intertribal Activism
Authors: Shreve Bradley G.
Published: June 2009

This article explores the fish-in movement of the 1960s, uncovering the roots of modern intertribal activism. Fish-ins as intertribal activism began in March 1964 when the National Indian Youth Council (NIYC) brought together Native people in the Pacific Northwest and beyond to protest the arrests of local Native fishermen whom Washington State game officials charged with violating conservation laws and fishing out of season. The NIYC contended that the wardens had violated Native peoples' right to fish at "all usual and accustomed places" as guaranteed by federal treaties. Modeled after African American student sit-ins, fish-ins were a form of civil disobedience designed to produce arrests, garner media attention, and highlight abrogated rights. Tapping recently opened archives, including NIYC Records, Washington State Sportsmen's Council Papers, and the Frederick Haley Papers, the article posits that NIYC fish-ins represent the first example of intertribal direct action and the beginning of the Red Power Movement.
The Invisible Presence: Cut-In, Close-Up, and Off-Scene in Antonello da Messina's Palermo Annunciate
Authors: Pericolo Lorenzo
Published: June 2009

Antonello da Messina's Palermo Annunciate (c. 1475) is usually construed as the equivalent of an icon. Relying on the iconography of the fifteenth-century Flemish Annunciation, Lorenzo Pericolo demonstrates that Antonello's panel must rather be interpreted as a "truncated" narrative in the form of an icon. From this premise, Pericolo also unveils the experimental charge of some pictorial devices used by Antonello, such as close-up, cut-in, and off-scene.
A Molecular Mechanism of Temperature Sensitivity for Mutations Affecting the Drosophila Muscle Regulator Myocyte Enhancer Factor-2
Authors: Lovato TyAnna L , Adams Melanie M , Baker Phillip W , Cripps Richard M
Published: June 2009

Temperature-sensitive (TS) mutations are a useful tool for elucidating gene function where a gene of interest is essential at multiple stages of development. However, the molecular mechanisms behind TS alleles vary. TS mutations of the myogenic regulator Myocyte enhancer factor-2 (MEF2) in Drosophila arise in the heteroallelic combination Mef230-5/Mef244-5. We show that the 30-5 mutation affects the N-terminal MADS domain, causing impaired DNA binding ability and failure of homozygous mutants to survive to adulthood. The 44-5 mutation deletes a downstream splice acceptor site and results in a truncated protein that is unable to activate MEF2 targets. 44-5 homozygotes consequently show severely impaired myogenesis and die as embryos. We propose that in heteroallelic mutants at the permissive temperature, 30-5/44-5 heterodimers form and have a sufficiently stable interaction with DNA to activate myogenic gene expression; at the restrictive temperature, 44-5 homodimers displace 30-5/44-5 heterodimers from target genes, thus acting in a dominant-negative manner. To test this, we show that 30-5/44-5 heterodimers can form, and we study additional Mef2 alleles for complementation with the 30-5 allele. An allele affecting the DNA binding domain fails to complement 30-5, whereas two alleles affecting downstream residues show temperature-dependent complementation. Thus, by combining one MEF2 isoform having weakened DNA binding ability with a second truncated MEF2 mutant that has lost its activation ability, a TS form of intragenic complementation can be generated. These findings will provide new insight and guidance into the functions of dimeric proteins and how they might be engineered to generate TS combinations.
Alternative Splicing of PTC7 inSaccharomyces cerevisiaeDetermines Protein Localization
Authors: Juneau Kara , Nislow Corey , Davis Ronald W
Published: June 2009

It is well established that higher eukaryotes use alternative splicing to increase proteome complexity. In contrast, Saccharomyces cerevisiae, a single-cell eukaryote, conducts predominantly regulated splicing through retention of nonfunctional introns. In this article we describe our discovery of a functional intron in the PTC7 (YHR076W) gene that can be alternatively spliced to create two mRNAs that code for distinct proteins. These two proteins localize to different cellular compartments and have distinct cellular roles. The protein translated from the spliced mRNA localizes to the mitochondria and its expression is carbon-source dependent. In comparison, the protein translated from the unspliced mRNA contains a transmembrane domain, localizes to the nuclear envelope, and mediates the toxic effects of Latrunculin A exposure. In conclusion, we identified a definitive example of functional alternative splicing in S. cerevisiae that confers a measurable fitness benefit.
Pediatric Specialized Transport Teams Are Associated With Improved Outcomes
Authors: Orr Richard A. , Felmet Kathryn A. , Han Yong , McCloskey Karin A. , Dragotta Michelle A. , Bills Debra M. , Kuch Bradley A. , Watson R. Scott
Published: June 2009

OBJECTIVE: The goal was to test the hypothesis that interfacility transport performed by a pediatric critical care specialized team, compared with nonspecialized teams, would be associated with improved survival rates and fewer unplanned events during the transport process.

METHODS: A single-center, prospective, cohort study was performed between January 2001 and September 2002. A total of 1085 infants and children at referral community hospitals with requests for retrieval by the Children's Hospital of Pittsburgh transport team were studied; 1021(94%) were transported by a specialty team and 64 (6%) by nonspecialized teams. Unplanned events during the transport process and 28-day mortality rates were assessed.

RESULTS: Unplanned events occurred for 55 patients (5%) and were more common among patients transported by nonspecialized teams (61% vs 1.5%). Airway-related events were most common, followed by cardiopulmonary arrest, sustained hypotension, and loss of crucial intravenous access. After adjustment for illness severity, only the use of a nonspecialized team was independently associated with an unplanned event, and death was more common among patients transported by nonspecialized teams (23% vs 9%).

CONCLUSION: Transport of critically ill children to a pediatric tertiary care center can be conducted more safely with a pediatric critical care specialized team than with teams lacking specific training and expertise in pediatric critical care and pediatric transport medicine.
Carbon Monoxide is a Significant Mediator of Cardiovascular Status Following Preterm Birth
Authors: Stark Michael J. , Clifton Vicki L. , Wright Ian M.R.
Published: June 2009

OBJECTIVE: With male gender as a strong predictor of cardiovascular instability, we hypothesized that gender-specific differences in circulating carbon monoxide levels contributed to dysregulated microvascular function in preterm male infants.

METHODS: Infants born at 24 to 34 weeks of gestation (N = 84) were studied in a regional tertiary neonatal unit. Carboxyhemoglobin levels were measured through spectrophotometry in umbilical arterial blood and at 24, 72, and 120 hours after birth. Microvascular blood flow was determined through laser Doppler flowmetry.

RESULTS: Carboxyhemoglobin levels demonstrated a strong inverse relationship with gestational age (r = −0.636; P < .001) and were higher in boys (P = .032). Repeated-measures analysis of variance showed a significant decrease in arterial carboxyhemoglobin levels over time (P < .001), with significant between-subjects effects for gestational age (P = .011) and gender (P = .025). Positive correlations with microvascular blood flow at 24 hours of age (r = 0.495; P < .001) and 120 hours of age (r = 0.548; P < .001) were observed. With controlling for gestational age, carboxyhemoglobin levels at 72 hours were greater for infants who died in the first week of life (P = .035).

CONCLUSIONS: The gestational age- and gender-specific differences in carboxyhemoglobin levels and the relationship with dysregulated microvascular blood flow, a state related to greater illness severity and hypotension, are novel findings not confined solely to sick preterm infants. Both inducible heme oxygenase-dependent and non–heme oxygenase-dependent pathways may initially play a central role in carbon monoxide production, inducing pathophysiologic processes in a gender-specific manner.
Effects of Oseltamivir on Influenza-Related Complications in Children With Chronic Medical Conditions
Authors: Piedra Pedro A. , Schulman Kathy L. , Blumentals William A.
Published: June 2009

OBJECTIVE: This study investigated the influence of oseltamivir on influenza-related complications and hospitalizations for children and adolescents, 1 to 17 years of age, with chronic medical conditions or neurologic or neuromuscular disease.

METHODS: In a retrospective study, outcomes for patients who were given oseltamivir within 1 day after influenza diagnosis were compared with those for patients who received no antiviral therapy. Anonymous data from MarketScan databases (Thomson Reuters, Cambridge, MA) were used to identify patients from 6 influenza seasons between 2000 and 2006. The study outcomes were frequencies of pneumonia, respiratory illnesses other than pneumonia, otitis media, and hospitalization.

RESULTS: Oseltamivir was prescribed for 1634 patients according to the study criteria, and 3721 patients received no antiviral therapy for their influenza. After adjustment for demographic and medical history variables, oseltamivir was associated with significant reductions in the risks of respiratory illnesses other than pneumonia, otitis media and its complications, and all-cause hospitalization in the 14 days after influenza diagnosis. Analyses for 30 days after influenza diagnosis also showed significant risk reductions for respiratory illnesses other than pneumonia, otitis media and its complications, and all-cause hospitalization with oseltamivir.

CONCLUSION: When it was prescribed at influenza diagnosis, oseltamivir was associated with reduced risks of influenza-related complications and hospitalizations for children and adolescents at high risk of influenza complications.
Are Outcomes and Care Processes for Preterm Neonates Influenced by Health Insurance Status?
Authors: Brandon Gwieneverea D. , Adeniyi-Jones Susan , Kirkby Sharon , Webb David , Culhane Jennifer F. , Greenspan Jay S.
Published: June 2009

OBJECTIVE: The purpose of this work was to compare the processes of care and to evaluate outcomes of premature neonates delivered to women with Medicaid managed care versus private insurance.

DESIGN/METHODS: All of the infants born at <37 weeks' gestation between January 2001 and August 2005 in the ParadigmHealth database were included in these analyses (n = 24151). Infants were categorized by maternal health insurance status as private insurance or Medicaid managed care and analyzed for differences in demographic data and length of stay. For survivors, differences in respiratory care, nutritional, and maturational milestones were assessed. In addition, age to wean to open crib, weight gain, home oxygen, and apnea monitor use were compared. Adverse outcomes, including necrotizing enterocolitis, sepsis, severe intraventricular hemorrhage, severe retinopathy of prematurity, bronchopulmonary dysplasia, apnea, and mortality, were compared. Statistical tests used were Students t test, χ2, and Kruskall-Wallis test. Multiple logistic regression was performed after controlling for demographic variables.

RESULTS: Of the 24151 infants studied, 19046 (78.9%) had private insurance, and 5105 (21.1%) had Medicaid managed care. There were no differences in gestational age at birth; however, Medicaid managed care infants had lower birth weight, lower Apgar score at 5 minutes, increased incidence of necrotizing enterocolitis and bacterial sepsis, and longer length of stay. Of the surviving infants, more neonates with private insurance went home on oxygen and apnea monitors despite no differences found in the incidences of apnea or bronchopulmonary dysplasia between the groups. There were no differences in processes of care for feeding and respiratory milestones, but infants with Medicaid managed care weaned to an open crib later and had greater overall weight gain compared with infants with private insurance.

CONCLUSIONS: We speculate that, in addition to the known impact of insurance status on well-being at birth, Medicaid managed care is independently associated with adverse neonatal outcomes in preterm infants, as well as differences in neonatal intensive care discharge processes.
Chronic Fatigue Syndrome After Infectious Mononucleosis in Adolescents
Authors: Katz Ben Z. , Shiraishi Yukiko , Mears Cynthia J. , Binns Helen J. , Taylor Renee
Published: June 2009

OBJECTIVE: The goal was to characterize prospectively the course and outcome of chronic fatigue syndrome in adolescents during a 2-year period after infectious mononucleosis.

METHODS: A total of 301 adolescents (12–18 years of age) with infectious mononucleosis were identified and screened for nonrecovery 6 months after infectious mononucleosis by using a telephone screening interview. Nonrecovered adolescents underwent a medical evaluation, with follow-up screening 12 and 24 months after infectious mononucleosis. After blind review, final diagnoses of chronic fatigue syndrome at 6, 12, and 24 months were made by using established pediatric criteria.

RESULTS: Six, 12, and 24 months after infectious mononucleosis, 13%, 7%, and 4% of adolescents, respectively, met the criteria for chronic fatigue syndrome. Most individuals recovered with time; only 2 adolescents with chronic fatigue syndrome at 24 months seemed to have recovered or had an explanation for chronic fatigue at 12 months but then were reclassified as having chronic fatigue syndrome at 24 months. All 13 adolescents with chronic fatigue syndrome 24 months after infectious mononucleosis were female and, on average, they reported greater fatigue severity at 12 months. Reported use of steroid therapy during the acute phase of infectious mononucleosis did not increase the risk of developing chronic fatigue syndrome.

CONCLUSIONS: Infectious mononucleosis may be a risk factor for chronic fatigue syndrome in adolescents. Female gender and greater fatigue severity, but not reported steroid use during the acute illness, were associated with the development of chronic fatigue syndrome in adolescents. Additional research is needed to determine other predictors of persistent fatigue after infectious mononucleosis.
Elevated Cerebral Pressure Passivity Is Associated With Prematurity-Related Intracranial Hemorrhage
Authors: O'Leary Heather , Gregas Matthew C. , Limperopoulos Catherine , Zaretskaya Irina , Bassan Haim , Soul Janet S. , Di Salvo Donald N. , du Plessis Adré J.
Published: June 2009

OBJECTIVES: Cerebral pressure passivity is common in sick premature infants and may predispose to germinal matrix/intraventricular hemorrhage (GM/IVH), a lesion with potentially serious consequences. We studied the association between the magnitude of cerebral pressure passivity and GM/IVH.

PATIENTS AND METHODS: We enrolled infants <32 weeks' gestational age with indwelling mean arterial pressure (MAP) monitoring and excluded infants with known congenital syndromes or antenatal brain injury. We recorded continuous MAP and cerebral near-infrared spectroscopy hemoglobin difference (HbD) signals at 2 Hz for up to 12 hours/day and up to 5 days. Coherence and transfer function analysis between MAP and HbD signals was performed in 3 frequency bands (0.05–0.25, 0.25–0.5, and 0.5–1.0 Hz). Using MAP-HbD gain and clinical variables (including chorioamnionitis, Apgar scores, gestational age, birth weight, neonatal sepsis, and Score for Neonatal Acute Physiology II), we built a logistic regression model that best predicts cranial ultrasound abnormalities.

RESULTS: In 88 infants (median gestational age: 26 weeks [range 23–30 weeks]), early cranial ultrasound showed GM/IVH in 31 (37%) and parenchymal echodensities in 10 (12%) infants; late cranial ultrasound showed parenchymal abnormalities in 19 (30%) infants. Low-frequency MAP-HbD gain (highest quartile mean) was significantly associated with early GM/IVH but not other ultrasound findings. The most parsimonious model associated with early GM/IVH included only gestational age and MAP-HbD gain.

CONCLUSIONS: This novel cerebrovascular monitoring technique allows quantification of cerebral pressure passivity as MAP-HbD gain in premature infants. High MAP-HbD gain is significantly associated with GM/IVH. Precise temporal and causal relationship between MAP-HbD gain and GM/IVH awaits further study.
Urinary Tract Infections in 1- to 3-Month-Old Infants: Ambulatory Treatment With Intravenous Antibiotics
Authors: Doré-Bergeron Marie-Joëlle , Gauthier Marie , Chevalier Isabelle , McManus Barbara , Tapiero Bruce , Lebrun Sylvie
Published: June 2009

OBJECTIVE: The goal was to examine the feasibility of outpatient management for 1- to 3-month-old infants with febrile urinary tract infections.

METHODS: A cohort study was performed with all children 30 to 90 days of age who were evaluated for presumed febrile urinary tract infections in the emergency department of a tertiary-care pediatric hospital between January 1, 2005, and September 30, 2007. Patients were treated with intravenously administered antibiotics as outpatients in a day treatment center unless they met exclusion criteria, in which case they were hospitalized.

RESULTS: Of 118 infants included in the study, 67 (56.8%) were admitted to the day treatment center and 51 (43.2%) were hospitalized. The median age of day treatment center patients was 66 days (range: 33–85 days). The diagnosis of urinary tract infection was confirmed for 86.6% of patients treated in the day treatment center. Escherichia coli was identified in 84.5% of urine cultures; 98.3% of isolates were sensitive to gentamicin. Six blood cultures (10.3%) yielded positive results, 5 of them for E coli. Treatment with intravenously administered antibiotics in the day treatment center lasted a mean of 2.7 days. The mean number of visits, including appointments for voiding cystourethrography, was 2.9 visits. The rate of parental compliance with day treatment center visits was 98.3%. Intravenous access problems were seen in 8.6% of cases. Successful treatment in the day treatment center (defined as attendance at all visits, normalization of temperature within 48 hours, negative control urine and blood culture results, if cultures were performed, and absence of hospitalization from the day treatment center) was obtained for 86.2% of patients with confirmed urinary tract infections.

CONCLUSIONS: Ambulatory treatment of infants 30 to 90 days of age with febrile urinary tract infections by using short-term, intravenous antibiotic therapy at a day treatment center is feasible.
Early Nasal Continuous Positive Airway Pressure and Necrotizing Enterocolitis in Preterm Infants
Authors: Aly Hany , Massaro An N. , Hammad Tarek A. , Narang Sherry , Essers Jonah
Published: June 2009

BACKGROUND: The use of early nasal continuous positive airway pressure (ENCPAP) as the mode of initial respiratory support for very low birth weight (VLBW) infants has been increasing. The impact of CPAP and oxygen on gut mucosa and perfusion in premature infants is not known. The relation between ENCPAP and necrotizing enterocolitis (NEC) has not been adequately addressed.

OBJECTIVE: To evaluate if the use of an individualized respiratory management strategy encouraging the use of ENCPAP is associated with an increased risk of NEC, and to determine risk factors for NEC in premature infants supported by CPAP.

METHODS: A retrospective analysis was conducted on VLBW infants (birth weight < 1500 g) managed at 2 institutions that use an ENCPAP respiratory management strategy for premature infants. Data on the use of oxygen and mode of ventilatory support were collected during the first 3 days of life. Diagnosis of NEC was used as the dependent variable in a logistic regression model. Birth weight, gender, prenatal steroid use, mode of respiratory support (CPAP versus ventilator) and fraction of inspired oxygen, umbilical artery catheter placement, partial pressure of oxygen, patent ductus arteriosus, early sepsis, hospital, and delivery room management (ENCPAP versus initial intubation) were controlled for in the model.

RESULTS: Data on 343 premature infants were collected for this study. Mean birth weight was 999 ± 289 g and gestational age was 28 ± 2.6 weeks. The majority of patients were managed with ENCPAP, with only 13% of patients intubated in the delivery room. The overall incidence of NEC was 7% (n = 24). The exposure to ENCPAP did not increase the risk for NEC compared with the use of a ventilator.

CONCLUSIONS. The risk of NEC in VLBW premature infants was not increased by the use of ENCPAP. Initial respiratory support with ENCPAP seems to be a safe alternative to routine intubation and mechanical ventilation in premature infants.
Low-Income Parents' Views on the Redesign of Well-Child Care
Authors: Coker Tumaini R. , Chung Paul J. , Cowgill Burton O. , Chen Leian , Rodriguez Michael A.
Published: June 2009

OBJECTIVE: To examine the perspectives of low-income parents on redesigning well-child care (WCC) for children aged 0 to 3 years, focusing on possible changes in 3 major domains: providers, locations, and formats.

METHODS: Eight focus groups (4 English and 4 Spanish) were conducted with 56 parents of children aged 6 months to 5 years, recruited through a federally qualified health center. Discussions were recorded, transcribed, and analyzed by using the constant comparative method of qualitative analysis.

RESULTS: Parents were mostly mothers (91%), nonwhite (64% Latino, 16% black), and <30 years of age (66%) and had an annual household income of <$35000 (96%). Parents reported substantial problems with WCC, focusing largely on limited provider access (especially with respect to scheduling and transportation) and inadequate behavioral/developmental services. Most parents endorsed nonphysician providers and alternative locations and formats as desirable adjuncts to usual physician-provided, clinic-based WCC. Nonphysician providers were viewed as potentially more expert in behavioral/developmental issues than physicians and more attentive to parent-provider relationships. Some alternative locations for care (especially home and day care visits) were viewed as creating essential context for providers and dramatically improving family convenience. Alternative locations whose sole advantage was convenience (eg, retail-based clinics), however, were viewed more skeptically. Among alternative formats, group visits in particular were seen as empowering, turning parents into informal providers through mutual sharing of behavioral/developmental advice and experiences.

CONCLUSIONS: Low-income parents of young children identified major inadequacies in their WCC experiences. To address these problems, they endorsed a number of innovative reforms that merit additional investigation for feasibility and effectiveness.
Unimpaired Outcomes for Extremely Low Birth Weight Infants at 18 to 22 Months
Authors: Gargus Regina A. , Vohr Betty R. , Tyson Jon E. , High Pamela , Higgins Rosemary D. , Wrage Lisa A. , Poole Kenneth
Published: June 2009

OBJECTIVE: The goal was to identify, among extremely low birth weight (≤1000 g) live births, the proportion of infants who were unimpaired at 18 to 22 months of corrected age.

METHODS: Unimpaired outcome was defined as Bayley Scales of Infant Development II scores of ≥85, normal neurologic examination findings, and normal vision, hearing, swallowing, and walking. Outcomes were determined for 5250 (86%) of 6090 extremely low birth weight inborn infants.

RESULTS: Of the 5250 infants whose outcomes were known at 18 months, 850 (16%) were unimpaired, 1153 (22%) had mild impairments, 1147 (22%) had moderate/severe neurodevelopmental impairments, and 2100 (40%) had died. Unimpaired survival rates varied according to birth weight, from <1% for infants ≤500 g to 24% for infants 901 to 1000 g. The regression model to predict unimpaired survival versus death or impairment for live births (N = 5250) indicated that 25.3% of the variance was derived from infant factors present at birth, including female gender, higher birth weight, singleton birth. The regression model to predict unimpaired survival for discharged infants indicated that most of the variance was derived from combined effects of major neonatal morbidities, neonatal interventions, and maternal demographic features (15.7%) and only 8.5% was derived from infant factors present at birth.

CONCLUSIONS: Although <1% of live-born infants of ≤500 g survive free of impairment at 18 months, this increases to almost 24% for infants of 901 to 1000 g. Female gender, singleton birth, higher birth weight, absence of neonatal morbidities, private health insurance, and white race increase the likelihood of unimpaired status.
Impact of Electronic Health Record-Based Alerts on Influenza Vaccination for Children With Asthma
Authors: Fiks Alexander G. , Hunter Kenya F. , Localio A. Russell , Grundmeier Robert W. , Bryant-Stephens Tyra , Luberti Anthony A. , Bell Louis M. , Alessandrini Evaline A.
Published: June 2009

OBJECTIVE: The goal was to assess the impact of influenza vaccine clinical alerts on missed opportunities for vaccination and on overall influenza immunization rates for children and adolescents with asthma.

METHODS: A prospective, cluster-randomized trial of 20 primary care sites was conducted between October 1, 2006, and March 31, 2007. At intervention sites, electronic health record-based clinical alerts for influenza vaccine appeared at all office visits for children between 5 and 19 years of age with asthma who were due for vaccine. The proportion of captured immunization opportunities at visits and overall rates of complete vaccination for patients at intervention and control sites were compared with those for the previous year, after standardization for relevant covariates. The study had >80% power to detect an 8% difference in the change in rates between the study and baseline years at intervention versus control practices.

RESULTS: A total of 23 418 visits and 11 919 children were included in the study year and 21 422 visits and 10 667 children in the previous year. The majority of children were male, 5 to 9 years of age, and privately insured. With standardization for selected covariates, captured vaccination opportunities increased from 14.4% to 18.6% at intervention sites and from 12.7% to 16.3% at control sites, a 0.6% greater improvement. Standardized influenza vaccination rates improved 3.4% more at intervention sites than at control sites. The 4 practices with the greatest increases in rates (≥11%) were all in the intervention group. Vaccine receipt was more common among children who had been vaccinated previously, with increasing numbers of visits, with care early in the season, and at preventive versus acute care visits.

CONCLUSIONS: Clinical alerts were associated with only modest improvements in influenza vaccination rates.
Effectiveness of Amoxicillin/Clavulanate Potassium in the Treatment of Acute Bacterial Sinusitis in Children
Authors: Wald Ellen R. , Nash David , Eickhoff Jens
Published: June 2009

OBJECTIVE: The role of antibiotic therapy in managing acute bacterial sinusitis (ABS) in children is controversial. The purpose of this study was to determine the effectiveness of high-dose amoxicillin/potassium clavulanate in the treatment of children diagnosed with ABS.

METHODS: This was a randomized, double-blind, placebo-controlled study. Children 1 to 10 years of age with a clinical presentation compatible with ABS were eligible for participation. Patients were stratified according to age (<6 or ≥6 years) and clinical severity and randomly assigned to receive either amoxicillin (90 mg/kg) with potassium clavulanate (6.4 mg/kg) or placebo. A symptom survey was performed on days 0, 1, 2, 3, 5, 7, 10, 20, and 30. Patients were examined on day 14. Children's conditions were rated as cured, improved, or failed according to scoring rules.

RESULTS: Two thousand one hundred thirty-five children with respiratory complaints were screened for enrollment; 139 (6.5%) had ABS. Fifty-eight patients were enrolled, and 56 were randomly assigned. The mean age was 66 ± 30 months. Fifty (89%) patients presented with persistent symptoms, and 6 (11%) presented with nonpersistent symptoms. In 24 (43%) children, the illness was classified as mild, whereas in the remaining 32 (57%) children it was severe. Of the 28 children who received the antibiotic, 14 (50%) were cured, 4 (14%) were improved, 4 (14%) experienced treatment failure, and 6 (21%) withdrew. Of the 28 children who received placebo, 4 (14%) were cured, 5 (18%) improved, and 19 (68%) experienced treatment failure. Children receiving the antibiotic were more likely to be cured (50% vs 14%) and less likely to have treatment failure (14% vs 68%) than children receiving the placebo.

CONCLUSIONS: ABS is a common complication of viral upper respiratory infections. Amoxicillin/potassium clavulanate results in significantly more cures and fewer failures than placebo, according to parental report of time to resolution of clinical symptoms.
Serum Gentamicin Concentrations in Encephalopathic Infants are Not Affected by Therapeutic Hypothermia
Authors: Liu Xun , Borooah Manobi , Stone Janet , Chakkarapani Ela , Thoresen Marianne
Published: June 2009

OBJECTIVE. Mild hypothermia for 72 hours is neuroprotective in newborns with moderate or severe hypoxic-ischemic encephalopathy. A core temperature of 33.5°C might reduce drug clearance leading to potential toxicity. Gentamicin is nephrotoxic and ototoxic at high serum concentrations. No study has investigated the influence of 72 hours of hypothermia on serum gentamicin concentrations (SGCs) in children of any age. We aimed to compare the SGCs in encephalopathic infants who underwent intensive care with therapeutic hypothermia or normothermia.

METHODS. Data were collected retrospectively from 2 NICUs in Bristol, United Kingdom, that offered cooling therapy within clinical trials since 1998. Eligible infants (n = 55) developed grade 2/3 encephalopathy after birth and fulfilled the entry criteria defined in the CoolCap trial. Encephalopathic infants with similar demographic values were either nursed under normothermia or 72 h-hypothermia. Once-daily gentamicin dosage (4–5 mg/kg) was administered, and trough SGC was recorded with corresponding creatinine concentrations. The time and number of omitted drug doses were noted.

RESULTS. Mean trough SGC (pre–second dose) and mean plasma creatinine concentrations for both treatment groups were similar (gentamicin: 2.19 ± 1.7 [hypothermia] and 2.30 ± 2.0 [normothermia] mg/L; creatinine: 115.6 ± 42.8 [hypothermia] and 121.0 ± 45.1 [normothermia] μmol/L). Forty percent of the trough SGCs in both groups were above the recommended trough concentration of 2.0 mg/L. A significant correlation (r2 = 0.36) was found between high SGCs and impaired renal function assessed by raised plasma creatinine levels regardless of treatment options.

CONCLUSIONS. Our data confirm that impaired renal function is strongly associated with high SGCs. Reduced body temperatures do not affect the clearance of gentamicin.
Primary Care Follow-up Plans for Adolescents With Substance Use Problems
Authors: Hassan Areej , Harris Sion Kim , Sherritt Lon , Van Hook Shari , Brooks Traci , Carey Peggy , Kossack Robert , Kulig John , Knight John R.
Published: June 2009

OBJECTIVE: Primary care visits provide an opportunity to screen adolescents for substance use and offer early intervention, but little is known about follow-up plans. The objective of this study was to determine recommendations by PCPs and assess the relationship between their diagnostic impressions of substance use severity and plans for intervention.

METHODS: Data were collected through a prospective observational study conducted at 7 primary care practices in New England. Patients aged 12 to 18 years completed an interview, which included sociodemographic characteristics and the CRAFFT substance abuse screen. PCPs received screen results, noted their diagnostic impression of participants' substance use severity, and recorded follow-up plans. Follow-up plans other than “periodic screening” alone were defined as “active intervention.” We examined the relationship of provider impressions with follow-up recommendations by using the χ2 test.

RESULTS: For 2034 adolescents, PCPs recommended no plan for 369 patients, periodic screening for 1557 patients, a return visit for 98 patients, and referral to counseling for 44 patients. PCPs' diagnostic impressions identified 97 (4.8%) patients with problem use and 19 (0.01%) patients with abuse or dependence. Recommendations for active intervention were more likely with patients' higher severity of use. However, 1 in 5 patients thought to have problem use did not receive a recommendation for an active intervention. Parent notification was planned for only 13 patients.

CONCLUSIONS: When concerned about substance use, PCPs recommend a return visit to their office more than twice as often as referral to counseling, and rarely planned to engage parents. PCPs need enhanced training and strategies for delivery of office-based interventions.
Delivery Indications at Late-Preterm Gestations and Infant Mortality Rates in the United States
Authors: Reddy Uma M. , Ko Chia-Wen , Raju Tonse N.K. , Willinger Marian
Published: June 2009

OBJECTIVE: The rate of preterm births has been increasing in the United States, especially for births 34 to 36 weeks of gestation (late preterm), which now constitute 71% of all preterm births. The causes for these trends remain unclear. We characterized the delivery indications for late preterm births and their potential impact on neonatal and infant mortality rates.

PATIENTS AND METHODS: Using the 2001 US Birth Cohort Linked birth/death files of 3 483 496 singleton births, we categorized delivery indications as follows: (1) maternal medical conditions; (2) obstetric complications; (3) major congenital anomalies; (4) isolated spontaneous labor: vaginal delivery without induction and without associated medical/obstetric factors; and (5) no recorded indication.

RESULTS: Of the 292 627 late-preterm births, the first 4 categories (those with indications and isolated spontaneous labor) accounted for 76.8%. The remaining 23.2% (67 909) were classified as deliveries with no recorded indication. Factors significantly increasing the chance of no recorded indication were older maternal age; non-Hispanic, white mother; ≥13 years of education; Southern, Midwestern, and Western region; multiparity; or previous infant with a ≥4000-g birth weight. The neonatal and infant mortality rates were significantly higher among deliveries with no recorded indication compared with deliveries secondary to isolated spontaneous labor but lower compared with deliveries with an obstetric indication or congenital anomaly.

CONCLUSIONS: A total of 23% of late preterm births had no recorded indication for delivery noted on birth certificates. Patient factors may be playing a role in these deliveries. It is concerning that these infants had higher mortality rates compared with those born after spontaneous labor at similar gestational ages. Given the excess risk of mortality, patients and providers need to discuss the risks of delivering a preterm infant in the absence of medical indications at 34 to 36 weeks.
The Use of Internet-Based Technology to Tailor Well-Child Care Encounters
Authors: Bergman David Aaron , Beck Arne , Rahm Alanna Kulchak
Published: June 2009

OBJECTIVE: The goal was to evaluate the feasibility and acceptance of a new model for well-child care (WCC) in a large health maintenance organization.

METHODS: We designed a new model of WCC that engages families in Internet-based developmental and behavioral screening, allows for review of the results before the visit, and allows for selection of the appropriate visit type (e-visit, e-visit with brief provider visit, or extended encounter). The new model was pilot-tested in 2 practices within a large health maintenance organization. Seven providers and 70 parents participated in the study. Parents and providers were surveyed regarding their experience and satisfaction with the encounter.

RESULTS: Seventy-five percent of parents thought that the online previsit assessment improved or very much improved the WCC visit. However, 12% of parents found the online assessment somewhat or very difficult to use. All of the parents found the e-visit or the e-visit with brief provider visit acceptable or very acceptable, compared with a standard WCC visit. All 7 providers thought that use of the new model helped focus the visit and that they would continue or definitely continue to use the model.

CONCLUSIONS: We demonstrated the feasibility of a new model of WCC that engaged parents in previsit assessment and used alternative visit types to tailor care to the needs of the family. Future research will be needed to examine the impact of this model on important WCC outcomes.
Epinephrine Auto-injectors: Is Needle Length Adequate for Delivery of Epinephrine Intramuscularly?
Authors: Stecher Dawn , Bulloch Blake , Sales Justin , Schaefer Carrie , Keahey Laine
Published: June 2009

OBJECTIVE: Studies show that intramuscular epinephrine results in peak plasma concentrations of epinephrine faster than the subcutaneous route, and therefore, epinephrine is recommended to be administered intramuscularly. The objective of this study was to determine if the needle length on epinephrine auto-injectors is adequate to deliver epinephrine intramuscularly in children.

METHODS: Patients between the ages of 1 and 12 years who presented to a children's hospital were enrolled in the study. Ultrasound was used to determine the depth from the skin to the vastus lateralis muscle. The patient's body mass index was recorded. The data were analyzed using simple descriptive statistics, and logistic regression was used to identify variables that might predict whether or not the needle length was exceeded.

RESULTS: A total of 256 children were enrolled. Of these, 158 children weighed less than 30 kilograms and would be prescribed the 0.15mg epinephrine auto-injector. Nineteen of these children (12%) had a skin to muscle surface distance of >½″ and would not receive epinephrine intramuscularly from current auto-injectors. There were 98 children weighing ≥30 kilograms who would receive the 0.3 mg epinephrine auto-injector. Of these 98 children, a total of 29 (30%) had a skin to muscle surface distance of >⅝″ and would not receive epinephrine intramuscularly.

CONCLUSION: The needle on epinephrine auto-injectors is not long enough to reach the muscle in a significant number of children. Increasing the needle length on the auto-injectors would increase the likelihood that more children receive epinephrine by the recommended intramuscular route.
Pathways to Approval of Pediatric Cardiac Devices in the United States: Challenges and Solutions
Authors: Beekman Robert H. , Duncan Brian W. , Hagler Donald J. , Jones Thomas K. , Kugler John D. , Moore John W. , Jenkins Kathy J. ,   for the Workgroup on Pediatric Cardiac Devices, Section on Cardiology and Cardiac Surgery, American Academy of Pediatrics
Published: June 2009

Patients treated by pediatric interventional cardiologists and cardiac surgeons often have unmet medical device needs that pose a challenge to the current regulatory evaluation and approval process in the United States. In this report we review current US Food and Drug Administration regulatory processes, review some unique aspects of pediatric cardiology and cardiac surgery that pose challenges to these processes, and discuss possible alternate pathways to cardiac device evaluation and approval for children. Children deserve to benefit from new and refined cardiac devices and technology designed explicitly for their conditions.
Should a Head-Injured Child Receive a Head CT Scan? A Systematic Review of Clinical Prediction Rules
Authors: Maguire Jonathon L. , Boutis Kathy , Uleryk Elizabeth M. , Laupacis Andreas , Parkin Patricia C.
Published: June 2009

CONTEXT: Given radiation- and sedation-associated risks, there is uncertainty about which children with head trauma should receive cranial computed tomography (CT) scanning. A high-quality and high-performing clinical prediction rule may reduce this uncertainty.

OBJECTIVE: To systematically review the quality and performance of published clinical prediction rules for intracranial injury in children with head injury.

METHODS: Medline and Embase were searched in December 2008. Studies were selected if they included clinical prediction rules involving children aged 0 to 18 years with a history of head injury. Prediction-rule quality was assessed by using 14 previously published items. Prediction-rule performance was evaluated by rule sensitivity and the predicted frequency of CT scanning if the rule was used.

RESULTS: A total of 3357 titles and abstracts were assessed, and 8 clinical prediction rules were identified. For all studies, the rule derivations were reported; no study validated a rule in a separate population or assessed its impact in actual practice. The rules differed considerably in population, predictors, outcomes, methodologic quality, and performance. Five of the rules were applicable to children of all ages and severities of trauma. Two of these were high quality (≥11 of 14 quality items) and had high performance (lower confidence limits for sensitivity >0.95 and required ≤56% to undergo CT). Four of the 8 rules were applicable to children with minor head injury (Glasgow coma score ≥13). One of these had high quality (11 of 14 quality items) and high performance (lower confidence limit for sensitivity = 0.94 and required 13% to undergo CT). Four of the 8 rules were applicable to young children, but none exhibited adequate quality or performance.

CONCLUSIONS: Eight clinical prediction-rule derivation studies were identified. They varied considerably in population, methodologic quality, and performance. Future efforts should be directed toward validating rules with high quality and performance in other populations and deriving a high-quality, high-performance rule for young children.