bluuebunny/crossref_metadata_2025 huggingface dataset:
Measuring the Cost of Neonatal and Perinatal Care
Authors: Rogowski Jeannette
Published: December 2021

This article provides an overview of neonatal intensive care unit (NICU) treatment costs. It discusses data sources as well as the methods for measuring costs, contrasting the strengths and weaknesses of alternate approaches. In addition, detailed information on NICU treatment costs is presented from a nationally representative sample of 25 hospitals with NICUs. The sample consists of 3288 very low birth weight infants (≤1500 g at birth) with admission dates between January 1, 1993, and September 30, 1994. Information on median treatment cost per infant, ancillary costs, accommodation costs, length of stay, and cost per day are presented. In addition, ancillary costs are disaggregated further into those for respiratory therapy, laboratory, radiology, pharmacy, and all other ancillary services.
Reducing Cesarean Birth Rates With Data-driven Quality Improvement Activities
Authors: Main Elliott K.
Published: December 2021

Reduction of cesarean section rates has been a difficult process that has not been easily accomplished by the institution of guidelines. It is more a process of changing physician behavior rather than of medical education. This article analyzed the role of intensive feedback of outcomes to bring about such changes. Two large private obstetric services in San Francisco, CA, were studied. Intensive outcomes feedback using a computerized information system, The Perinatal Data Center, regarding cesarean birth rates and a variety of obstetric outcomes was provided to the medical and nursing staff at one hospital. The other center served as a control. After the first observation period, the outcomes system was introduced to the second hospital. Finally, “open label” feedback, intradepartmental release of everyone's key statistics with names attached, was performed. Active management of labor was not practiced at either hospital.

Results. Cesarean birth rates were stable in the baseline period from 1980 through 1988 at 24% to 25%. Introduction of the Perinatal Data Center outcomes system was associated with a reduction to 21% at the first hospital with no change in the control hospital. Subsequent introduction of the system 3 years later in the control hospital resulted in a decline from 25% to 20.5%. After merger of the two obstetric units and the institution of “open label” feedback, an additional decline to 18.5% was observed.

Conclusion. Physician practice patterns and cesarean birth rates can be altered with the intensive use of comparative outcome data and strong physician leadership. Nonblinded, intradepartmental distribution of outcomes is an even more effective tool.
The Academic General Pediatrician: Is the Species Still Endangered?
Authors: Haggerty Robert J. , Sutherland Sydney A.
Published: December 2021

Objective.

To determine the careers of graduates of the General Pediatrics Academic Development Program (GPADP) and the pediatricians from the Clinical Scholars (CS) Program 8 to 16 years after completion of their fellowship to assess the current state of the academic general pediatrician and to determine the current activities of divisions of General Pediatrics in US medical schools.

Design.

Analysis of questionnaire data from former fellows of the two programs, who trained during the years 1978 to 1988, as well as of data from questionnaires to all divisions of General Pediatrics (or their equivalent) in all medical schools in the United States.

Population.

Surveys were conducted of the 111 graduates of the GPADP and the 39 pediatricians from the CS program and all 127 US medical schools.

Results.

Of the 111 GPADP graduates, 101 were located, and 85 completed the questionnaire. Of 39 CS graduates, 36 were located, of whom 27 completed the questionnaire. Similarities were found between the two groups in percent being in academic positions (74%, GPADP vs 70.4%, CS), percent having achieved tenure (17.8%, GPADP vs 14.3%, CS), and percent of time spent in research (17%, GPADP vs 25%, CS). Considerable differences, however, were found in percent of time spent in direct patient care (35.7% time for GPADP and only 17.8% time for CS) and in direct teaching (25.1% time for GPADP and only 17.6% time for CS). The mean number of articles published was greater among CS professionals (21.4 vs 14 for GPADP, but not statistically significant), as was the mean number of research grants (6.75 by CS vs 4.02 by GPADP). The GPADP fellows had obtained more education grants and more service grants. Both groups were concerned about the lack of time and support for research. Few General Pediatrics divisions had ongoing academic fellowship programs.

The current number of new fellows by divisions of General Pediatrics who are educated to do research is small. Only 30 related programs exist in all the medical schools in the United States. However, large divisions of General Pediatrics, responsible for large teaching and clinical service programs, are now in place in the majority of medical schools. This represents progress since 1978, when few generalists were in full-time academia.

Conclusion.

More than two thirds of both the GPADP graduates and CS professionals are now in academic departments. They have had modest success in obtaining grants, publishing articles, and achieving tenure, but large teaching and service demands and lack of research funds have made it difficult for both groups to be as productive in research as originally hoped. The field of Academic General Pediatrics now is established. It is the responsibility of graduates of these and similar programs to produce creative research and expand fellowship programs, as well as to do good clinical care, if a vigorous field of Academic General Pediatrics is to be achieved.
A Medical Research Agenda for Child Maltreatment: Negotiating the Next Steps
Authors: Theodore Adrea D. , Runyan Desmond K.
Published: December 2021

Child maltreatment remains a significant pediatric health problem despite 25 years since the establishment of the National Center on Child Abuse and Neglect. Federal funding for research on the medical aspects of abuse and neglect has been inadequate and, over time, declining in adjusted dollars. Nevertheless, important research has been conducted without federal support. Landmark research has occurred in the areas of physical abuse, sexual abuse, and neglect. Some of these accomplishments are noted, and a research agenda for future work is suggested.
Patient Recruitment: US Perspective
Authors: Walson Philip D.
Published: December 2021

There are many ethical, legal, economic, scientific, and practical problems associated with conducting drug trials in children. The single most difficult is subject identification and enrollment (ie, recruitment). This article reviews various aspects of the recruitment process and proposes potential solutions to recruitment problems.
On Pins and Needles? Pediatric Pain Patients' Experience With Acupuncture
Authors: Kemper Kathi J. , Sarah Rebecca , MPH LicAc, , Silver-Highfield Ellen , Xiarhos LicAc§; Elizabeth , Barnes Linda , Berde Charles
Published: December 2021

Introduction.

Despite its increasing use as a complementary therapy to treat pain, acupuncture is rarely considered by pediatricians, in part due to perceptions that it will not be acceptable to pediatric patients. We wished to describe pediatric pain patients' experience with acupuncture treatment for chronic pain.

Design.

Retrospective case series.

Methods.

Subjects were pediatric pain patients referred by the Pain Treatment Service at Children's Hospital in Boston, who went to a pediatric acupuncturist. A research assistant not involved in the patient's care conducted the survey by telephone. Data were analyzed qualitatively and descriptively.

Results.

Of 50 eligible patients, 47 families were reached by telephone; all agreed to be interviewed. Patients had a median age of 16 years at the time of referral, 79% were female, and 96% were white. The most common three diagnoses were migraine headache (n = 7), endometriosis (n = 6), and reflex sympathetic dystrophy (n = 5). Patients had a median of 8 treatments (range: 0–60) within 3 months (range: 0–48 months); 85% of families paid out-of-pocket. Acupuncture therapies included needle insertion (98%), heat/moxa (85%), magnets (26%), and cupping (26%). Most patients and parents rated the therapy as pleasant (67% children/60% parents), and most (70% children/59% parents) felt the treatment had helped their symptoms; only 1 said that treatment made symptoms worse.

Conclusion.

Pediatric patients with chronic, severe pain found acupuncture treatment pleasant and helpful. Additional, prospective studies are needed to quantify the costs and effectiveness of acupuncture treatment for pediatric pain.
Reliabilities of Short Substance Abuse Screening Tests Among Adolescent Medical Patients
Authors: Knight John R. , Goodman Elizabeth , Pulerwitz Todd , DuRant Robert H.
Published: December 2021

Objective.

To determine the internal consistency and 1-week test-retest reliability of the Simple Screening Instrument for Alcohol and Other Drug Abuse (SSI-AOD), the CAGE-AA (CAGE questions adapted for adolescents), and 4 modified items from the Drug and Alcohol Problem QuickScreen (DAP-4) among adolescents.

Methods.

Fifteen- to 18-year-old medical patients (n = 173) completed screening tests during a routine medical visit and then again 1 week later. Internal consistency for each test and retest was calculated using Cronbach's α, and 1-week test-retest reliability was calculated by using Winer's unbiased estimate of the intraclass correlation coefficient (r).

Results.

The SSI-AOD has good internal consistency (α = .83) and the CAGE-AA questions acceptable internal consistency (α = .60). Alpha varied with gender and race, and item analysis indicated the CAGE-AA test could be improved. As expected, the DAP-4 had a lower α score (.46). All screening instruments studied had high 1-week test-retest reliabilities (ranger = .82–.90).

Conclusions.

The SSI-AOD is a reliable substance abuse screening instrument among adolescent medical patients. The CAGE-AA questions must be further revised and tested before their use can be recommended. The DAP-4 questions are likely measuring different, but important, constructs.
Does Being a Chief Resident Predict Leadership in Pediatric Careers?
Authors: Alpert Joel J. , Levenson Suzette M. , Osman Cindy J. , James Sabin
Published: December 2021

Objective.

Many organizations make efforts to identify future pediatric leaders, often focusing on chief residents (CRs). Identifying future leaders is an issue of great importance not only to the ultimate success of the organization but also to the profession. Because little is known regarding whether completing a CR predicts future leadership in medicine, we sought to determine if former pediatric CRs when compared with pediatric residents who were not CRs reported more often that they were leaders in their profession.

Design/Methods.

Twenty-four pediatric training programs stratified by resident size (<18, 18–36, and >36) and geography (East, South, Midwest, and West) were selected randomly from the Graduate Medical Education Directory(American Medical Association, Chicago, IL). Program directors were contacted by mail and telephone and asked to provide their housestaff rosters from 1965–1985. The resulting resident sample was surveyed by questionnaire in 1995.

Results.

Fifteen of 17 program directors (88%) who possessed the requested data provided 1965–1985 rosters yielding a sample of 963 residents. Fifty-five percent of the resident sample (533) responded. Fifty-eight of the respondents had not completed a pediatric residency, leaving a survey sample of 475. Thirty-four percent (163) were CRs. The sample had a mean age of 47, 67% were male and 87% married. Fellowships were completed by 51%. More former CRs compared with non-CRs (75% vs 64%), more former fellows than non-fellows (75% vs 60%) and more males than females (74% vs 55%) reported they were professional leaders. These associations persisted in a logistic regression that controlled for CR status, gender, marital status, and fellowship status as leadership predictors. Former CRs, former fellows, and men were, respectively, 1.8, 2.3, and 2.3 times more likely to report professional leadership.

Conclusions.

Pediatric residents who were former CRs and/or fellows, and males were more likely to report professional leadership. Although men were more likely to report professional leadership, with more women entering pediatrics the reported gender differences will likely disappear over time.
The Unmet Health Needs of America's Children
Authors: Newacheck Paul W. , Hughes Dana C. , Hung Yun-Yi , Wong Sabrina , Stoddard Jeffrey J.
Published: December 2021

Objective.

Unmet need for health care is a critical indicator of access problems. Among children, unmet need for care has special significance inasmuch as the failure to obtain treatment can affect health status and functioning in the near- and long-term. The purpose of this study was to present current prevalence estimates and descriptive characteristics of children with unmet health needs using nationally representative household survey data.

Methods.

We analyzed 4 years of National Health Interview Survey data spanning 1993 through 1996. Our analysis included 97 206 children <18 years old. Measures of unmet need for medical care, dental care, prescription medications, and vision care were obtained from an adult household member (usually the mother) responding for the child. Bivariate and multivariate analyses were used to assess the degree to which unmet need was related to the demographic and socioeconomic characteristics of the child and family.

Results.

Overall, 7.3% (4.7 million) of US children experienced at least 1 unmet health care need. Dental care was the most prevalent unmet need. After adjustment for confounding factors, near-poor and poor children were both about 3 times more likely to have an unmet need as nonpoor children (adjusted odds ratio [95% confidence interval] = 2.89 [2.52, 3.32], 3.0 [2.53, 3.56], respectively). Uninsured children were also about 3 times more likely to have an unmet need as privately insured children (adjusted odds ratio [95% confidence interval] = 2.92 [2.58, 3.32]).

Conclusions.

Despite the nation's great wealth, unmet health needs remain prevalent among US children. A combined public policy that addresses financial and nonfinancial barriers to care is required to reduce the prevalence of unmet need for health care.
Evaluation of New York State's Child Health Plus: Methods
Authors: Szilagyi Peter G. , Shone Laura Pollard , Holl Jane L. , Rodewald Lance E. , Jennings Jacqueline , Zwanziger Jack , Mukamel Dana B. , Trafton Sarah , Dick Andrew W. , Barth Richard , Raubertas Richard F.
Published: December 2021

Background.

The State Children's Health Insurance Program (SCHIP) is the largest public investment in child health care in 30 years, targeting 11 million uninsured children, yet little is known about the impact of health insurance on uninsured children. In 1991 New York State implemented Child Health Plus (CHPlus), a health insurance program that was a prototype for SCHIP. A study was designed to measure the association between CHPlus and access to care, utilization of services, and quality of care.

Methods.

The setting was a 6-county region in upstate New York (population 1 million) around and including the city of Rochester. A before-and-during design was used to compare children's health care for the year before they enrolled in CHPlus versus the first year during CHPlus, for 1828 children (ages 0–6.99 years at enrollment) who enrolled between November 1, 1991 and August 1, 1993. An additional study involved 187 children 2 to 12.99 years old who had asthma. Parents were interviewed to assess demographic characteristics, sources of health care, experience with CHPlus, and impact of CHPlus on their children's quality of care and health status. Medical charts were reviewed to measure utilization and quality of care, for 1730 children 0 to 6.99 years and 169 children who had asthma. Charts were reviewed at all primary care offices and at the 12 emergency departments and 6 public health department clinics in the region. CHPlus claims files were analyzed to determine costs during CHPlus and to impute costs before CHPlus from utilization data.

Analyses.

Logistic regression and Poisson regression were used to compare the means of dependent measures with and without CHPlus coverage, while controlling for age, prior insurance type, and gap in insurance coverage before CHPlus.

Conclusions.

This study developed and implemented methods to evaluate the association between enrollment in a health insurance program and children's health care. These methods may also be useful for evaluations of SCHIP.
A Profile of the Population Enrolled in New York State's Child Health Plus
Authors: Holl Jane L. , Dick Andrew W. , Shone Laura Pollard , Rodewald Lance E. , Zwanziger Jack , Mukamel Dana B. , Trafton Sarah , Raubertas Richard F. , Szilagyi Peter G.
Published: December 2021

Background.

The recently enacted State Children's Health Insurance Program (SCHIP), designed to provide affordable health insurance for uninsured children, was modeled in part on New York State's Child Health Plus (CHPlus), which was implemented in 1991. All SCHIP programs involve voluntary enrollment of eligible children. Little is known about characteristics of children who enroll in these programs.

Objectives.

To provide a profile of children enrolled in CHPlus between 1993 and 1994 in the 6-county upstate New York study area, and to estimate the participation rate in CHPlus.

Methods.

A parent interview was conducted to obtain information about children, 0 to 6.9 years old, who enrolled in CHPlus in the study area. Two school-based surveys and the Current Population Survey were used to estimate health insurance coverage. Enrollment data from New York State's Department of Health, together with estimates of the uninsured, were used to estimate participation rates in CHPlus.

Results.

Most children enrolled in CHPlus in the study area were white. Although 17% of all children in the study area who were <13 years old and living in families with incomes below 160% of the federal poverty level were black, only 9% of CHPlus-enrolled children were black. Twenty-one percent of enrolled children were uninsured during the entire year before enrollment and 61% of children had a gap in coverage lasting >1 month. Children were generally healthy; only 4% had fair or poor health. Eighty-eight percent of parents of enrolled children had completed high school or a higher level of education. Parents reported that loss of a job was the main reason for loss of prior health insurance for their child. Most families learned about CHPlus from a friend (30%) or from their doctor (26%). The uninsured rate among children in the study area was approximately 4.1%. By 1993, the participation rate in CHPlus was about 36%.

Conclusion.

Blacks were underrepresented in CHPlus. Because the underlying uninsured rate was relatively low and parental education and family income were relatively high, the effects of CHPlus observed in this evaluation may be conservative in comparison to the potential effects of CHPlus for other populations of children. Participation rates during the early years of the program were modest.
HERPANGINA: CLINICAL AND LABORATORY ASPECTS OF AN OUTBREAK CAUSED BY GROUP A COXSACKIE VIRUSES
Authors: KRAVIS LILLIAN P. , HUMMELER KLAUS , SIGEL M. MICHAEL , LECKS HAROLD I.
Published: December 2021

The causal relationship between certain Coxsackie group A viruses and the disease entity herpangina first reported by Huebner and his associates in 1951 is confirmed.

Outbreaks of herpangina in Philadelphia during the summer of 1951 are described.

Coxsackie group A viruses of three different immunologic types were isolated from stools or throat swabs, or both, obtained from 17 of the 21 patients involved in the outbreaks.

A rise in complement-fixing and neutralizing antibody titers against homologous virus strains during convalescence was demonstrated in 3 patients.

Asymptomatic carriers of Coxsackie group A virus are described. Evidence is presented suggesting that two children with herpangina acquired their infection from such a carrier.

The criteria used in making a laboratory diagnosis of infection with Coxsackie virus are discussed.
FUNCTION OF ADRENAL CORTEX IN PREMATURE INFANTS
Authors: LANMAN JONATHAN T.
Published: December 2021

Urinary formaldehydogenic steroid excretions were measured in eight premature infants without recognized disease for varying periods up to 2 months of age. A balance study for Na, K and N was carried out in one infant.

Urinary formaldehydogenic steroid excretion did not change measurably during the first 10 days of life, and was not significantly different from adult normal values when compared on a surface area basis. Calculations from the data of other investigators indicate that infant values are from 1 to 5 times those of adults when compared by surface area.

Urinary formaldehydogenic steroid excretions rose significantly with age when the entire period of study for all infants was included. This rise occurred during the period of fetal cortical involution and is evidence that the fetal zone is not an important source of formaldehydogenic steroids.

The nitrogen and electrolyte balance study revealed a loss of K in the first 2 days of life which was disproportionately greater than the loss of N during the postnatal fasting period. The formaldehydogenic steroid excretion did not change measurably at this time, so that the study does not support the concept of changed adrenal function as a cause for this K/N disproportion. The electrolyte-regulating hormones can, however, vary independently of other adrenal functions. Acute inanition in the neonatal period of fasting is suggested as a possible cause for the disproportion.
EPIDEMIC SHIGELLA GASTROENTERITIS (BACILLARY DYSENTERY) IN AN ENDEMIC AREA
Authors: FEIG MILTON
Published: December 2021

The clinical aspects of acute bacillary dysentery as observed in an outbreak among a general population group in a highly endemic area are presented; age-specific clinical variations are noted.

The onset was abrupt in all cases and all age-groups. The height of the illness in 84% of 106 cases was reached in 24 hours, more rapidly than in the "classical" form (3 to 5 days).

The presence of blood in the stools was noted in about 25% of all cases; in about 25% of the 0 through 5 year age-group, 50% of the 6 through 10 year group, 37½% of the 11 through 15 year age-group, and 9 to 10% in the groups 16 years of age and over.

The median number of stools was 9 to 10 daily, with no significant difference among the various age-groups.

Fever was present in 65% of the children 10 years of age and under (55 cases), and in 35% of the older age-groups (40 cases).

Vomiting is more frequent among the younger age-groups; weakness becomes a more frequent complaint with advancing age.

The median duration of illness was 5.5 days in 100 cases. There was no correlation observed between age and duration.

Recurrences are more frequently observed in the youngest age-groups—36% of all cases (14) under one year of age, 28% of 39 cases between 1-2 years of age. About 9% of the 26 and over age-group (34 cases) recurred, and practically none in the intervening groups.

No relationship was observed between the tendency towards recurrences in households with multiple cases as compared with single cases.

All the fatalities were under one year of age. Two deaths occurred in the cases studied, yielding an age-specific death rate of 14.3% for this group. Five other deaths in cases not included in this report are noted, all under one year of age; 2 caused by "infant diarrhea" and 3 by bronchopneumonia with "chronic diarrhea" as a contributing cause.

The role of acquired immunity in the modification of bacillary dysentery can be evaluated from studies of attack rates and the clinical course of the disease, through age-specific groupings. Investigators should clearly define such basic terms as duration, recurrences, etc., when reporting so that necessary comparisons and/or data summation can be made.
CHEMOTHERAPEUTIC ASPECTS OF STUDIES ON BACTERIAL VIRUSES
Authors: COHEN SEYMOUR S.
Published: December 2021

MY GREAT pleasure in addressing this body stems in no small part from the fact that this occasion is almost the first indication I have had in 10 years that others besides my immediate chiefs at the Children's Hospital know why I am in a Department of Pediatrics. As many of you are aware, I am a biochemist. It is apparently a surprise to others of my profession that infectious disease is a problem of concern to both pediatricians and biochemists. This attitude, reflecting a tacit belief that the job of a biochemist is to study some esoteric compound, its origin or its fate, rather than chemical aspects of a clearly defined biologic problem is widely prevalent and can be a serious deterrent to the solution of many important medical problems. This is true in the sense that this view affects the general problem of uniting theoretic and practical work. I recall attending the dedication of a virology laboratory last year in which the guest speaker paid tribute to the contributions of research scientists who solved problems in the process of satisfying their intellectual curiosity, as well as to contributions of the research physician who undertook to solve the more practical aspects of the control of disease. It did not seem to have occurred to the speaker that a research scientist might be interested in doing more than titillating his neurones. And of course, in many instances, the speaker was unfortunately correct, since practicality is often viewed as only the unworthy illegitimate child of science, rather than merely as its natural offspring.
TREATMENT OF MENINGITIS WITH CHLOROMYCETIN PALMITATE®
Authors: DEANE GARRETT E. , FURMAN J. EARLE , BENTZ ALICE R. , WOODWARD THEODORE E.
Published: December 2021

Twenty-three patients with pyogenic meningitis were treated with chloramphenicol as the lone form of therapy. Chloromycetin hydrochloride was employed intravenously in 12 cases during the early stages of infection and chloromycetin palmitate® was employed as maintenance therapy. In 11 cases, oral chloromycetin palmitate® was used exclusively. This palatable form of chloramphenicol was well tolerated and produced measurable concentrations of antibiotic in the blood and spinal fluid. Of 23 patients treated, 22 recovered completely and one died. The fatality occurred in a critically ill child first treated on the eighth day of disease. Of the 22 recovered patients, 12 had meningitis caused by H. influenzae, 8 by N. intracellularis and 3 by D. pneumoniae.
Gestational Age, Parent Education, and Education in Adulthood
Authors: Bilsteen Josephine Funck , Alenius Suvi , Bråthen Magne , Børch Klaus , Ekstrøm Claus Thorn , Kajantie Eero , Lashkariani Mariam , Nurhonen Markku , Risnes Kari , Sandin Sven , van der Wel Kjetil A. , Wolke Dieter , Andersen Anne-Marie Nybo
Published: December 2021

BACKGROUND

Adults born preterm (<37 weeks) have lower educational attainment than those born term. Whether this relationship is modified by family factors such as socioeconomic background is, however, less well known. We investigated whether the relationship between gestational age and educational attainment in adulthood differed according to parents’ educational level in 4 Nordic countries.

METHODS

This register-based cohort study included singletons born alive from 1987 up to 1992 in Denmark, Finland, Norway, and Sweden. In each study population, we investigated effect modification by parents’ educational level (low, intermediate, high) on the association between gestational age at birth (25–44 completed weeks) and low educational attainment at 25 years (not having completed upper secondary education) using general estimation equations logistic regressions.

RESULTS

A total of 4.3%, 4.0%, 4.8%, and 5.0% singletons were born preterm in the Danish (n = 331 448), Finnish (n = 220 095), Norwegian (n = 292 840), and Swedish (n = 513 975) populations, respectively. In all countries, both lower gestational age and lower parental educational level contributed additively to low educational attainment. For example, in Denmark, the relative risk of low educational attainment was 1.84 (95% confidence interval 1.44 to 2.26) in adults born at 28 to 31 weeks whose parents had high educational level and 5.25 (95% confidence interval 4.53 to 6.02) in adults born at 28 to 31 weeks whose parents had low educational level, compared with a reference group born at 39 to 41 weeks with high parental educational level.

CONCLUSIONS

Although higher parental education level was associated with higher educational attainment for all gestational ages, parental education did not mitigate the educational disadvantages of shorter gestational age.
A NEED FOR PEDIATRIC GUIDANCE
Authors: Solnit Albert J.
Published: December 2021

Although psychotic states of childhood constitute only a small percentage of children's psychiatric and behavior disorders, there is an impressionistic consensus among pediatricians and child psychiatrists that there has been a significant increase of these conditions in clinical practice. Early valuable observational studies by Potter,1 Bradley,2 Kanner,3 Rank,4 and Putnam,5 and Bender and her group6 called attention to the autistic psychoses of childhood. In these reports there was a lack of consensus about etiological factors.

Initially, the formulations from these early studies led to a polarization of opinion about etiological factors with the extreme poles of biological (nature) and experiential (nurture) factors being well represented.
OUR CHALLENGES FOR THE 70'S President's Address, 1970
Authors: Mapes Russell W.
Published: December 2021

For any national organization striving to keep pace with increasingly diverse responsibilities and objectives, there are appropriate times when that organization must pause, reflect, and project before moving forward to meet the goals to which it has dedicated its programs and priorities.

This year marks the 40th anniversary of the American Academy of Pediatrics. It was June 23, 1930 that 35 pediatricians met in Harper Hospital in Detroit to establish the Academy as the organization to speak for the interests and health of children, as well as the interests of its pediatric members. This year also marks the beginning of a new decade, a decade which holds great promise for the future of pediatrics but a decade which also presents significant challenges which we must meet if we are to deliver quality health care to all children.

The American Academy of Pediatrics is indeed fortunate to be able to draw from the accomplishments of a progressive history of achievement, distinguished by the vision of its early founders. In the 1920's the medical community widely predicted that pediatrics was disappearing as a specialty, that in a few years it would merge into the field of general medicine. Concern was also expressed that pediatrics was not sufficiently represented in the echelons of organized medicine and, consequently, the cause of child health was not being served adequately.

To pediatricians like Isaac A. Abt, the first president of the Academy, to John L. Morse, its first vice-president, and to Clifford G. Grulee, the Academy's pioneering executive director, these were very real challenges, but they were not causes for pessimism or defeatism.
Letters to the Editor
Authors: Neumann Hans H.
Published: December 2021

The preceeding letters emphasize some very valid points, among them the fact that distortions of useful acts can become classifiable as symptoms, as Dr. Palmeri observes.

Regarding the comments by Dr. Leonard, Solnit, and Lourie: In the wide range of activities labelled pica, a variety of contributing or coexisting factors, such as emotional deprivation, cannot be ignored. There was certainly no intention to extend the conclusions to all deviant appetites. Dr. Gutelius emphasized the factor of ingestion in defining pica.
Hazards of Handling Antineoplastic Drugs (Continued)
Authors: Gottlieb Jeffrey A.
Published: December 2021

With regard to the letter of Dr. L. M. Ng, "Possible Hazards of Handling Antineoplastic Drugs" (Pediatrics, 46:648) mention should be made of the new experimental agent 1,3-bis (2-chloroethyl)-1-nitrosourea (BCNU). This drug, which is currently under extensive investigation See Images in the PDF file at many centers particularly with brain tumors and Hodgkin's disease,1,2 can cause intense dark brown discoloration of the skin (Fig. 1). This unsightly pigmentation, which appears several days after contact, is regularly produced by only a few drops of the drug.3
TRANSIT TIME RELATED TO CLINICAL FINDINGS IN CHILDREN WITH RECURRENT ABDOMINAL PAIN
Authors: Dimson Samuel B.
Published: December 2021

Carmine was used as a marker to estimate the transit time through the gut of 306 children with recurrent abdominal pain (RAP) of whom 96 had migraine as well. They were compared with a further 160 children with migraine alone.

Clinical examination revealed that having rectal constipation was present in 66 (22%) of children with RAP and transit was delayed in 91% of them. They presented distinctive features which suggest that rectal constipation alone may be a cause of RAP. In the remaining 240 children (78%) colonic spasm was thought to be responsible for attacks of abdominal pain. Transit time was prolonged in 44% and the colon was tender in 45% of cases. Colonic tenderness was associated more often with migraine and with a greater incidence and severity of intestinal delay than when colonic tenderness was absent. However in neither subgroup did the coexistence of migraine further delay intestinal transit. Children with migraine alone showed a delay in transit in 27% of cases, possibly accounted for mostly by colonic constipation, but delay is almost doubled in incidence and severity if abdominal pain supervenes with colonic tenderness.

It is suggested that when rectal constipation has been excluded, children with RAP should be classified as cases of colonic spasm in view of the strong similarity with spastic colon of adults.
PROGNOSIS IN NEWBORN INFANTS WITH X-CHROMOSOMAL ABNORMALITIES
Authors: Eller Eleanor , Frankenburg William , Puck Mary , Robinson Arthur
Published: December 2021

Sex-chromosomal aberrations occur with a relatively high frequency and have been associated with mental retardation, perceptual problems, psychopathology, and growth abnormalities. Identification of this possibly high risk group at birth enables the study of their growth and development to determine if and when they deviate from normal. Routine screening of the chromatin constitution of 21,214 consecutive newborn infants has identified 32 babies with gross X chromosome abnormalities. Three died in the newborn period. During the past 5 years, 27 children have been followed from birth. The evaluation process consists of semiannual and annual physical and developmental examinations, psychological testing, growth measurements, pedigree analysis, dermatoglyphic analysis, home environment evaluation, and, in mosaics, repeated chromosome analysis. The patients with 45,X karyotypes have classical physical signs. The other patients have normal phenotypes, although several have minor physical manifestations such as clinodactyly and epicanthic folds. Overall development in all except two patients has been within normal limits. In mosaics, there is a tendency for the abnormal cell line to disappear.
SOME FORGOTTEN PEDIATRIC DISEASES—WHAT EVER HAPPENED TO THEM?
Authors: C. T. E.
Published: December 2021

Diseases, like everything else, often fall out of favor and in time some well known to older generations of physicians are dropped entirely from contemporary textbooks. A sampling of diseases which have faded into oblivion is given below. Their names may evoke nostalgic remembrances especially among those of us who remember pediatric practice in the pre-antibiotic era.
COR TRIATRIATUM WITH INTACT SUBDIVIDING DIAPHRAGM AND PARTIAL ANOMALOUS PULMONARY VENOUS CONNECTION TO THE PROXIMAL LEFT ATRIAL CHAMBER (AN UNREPORTED TYPE)
Authors: Wilson James W. , Graham Thomas P. , Gehweiler John A. , Canent Ramon V.
Published: December 2021

The clinical, cardiac catheterization, and postmortem findings are presented in a 9-day-old infant with cor triatriatum, anomolous pulmonary venous connections, and a hypoplastic left ventricle.

The dorsal accessory left atrial chamber did not communicate with the ventral or proximal left atrium, but did have a small connection with the right atrium. The left superior pulmonary vein connected with the accessory left atrium while the left inferior pulmonary vein connected with the proximal left atrium. The latter pulmonary venous connection has not been described previously in classical cor triatriatum and raises new embryological considerations.
Pediatric Neurology, by Ingrid Gamstorp, M.D., D. Med. Sci. New York: Appleton-Century-Crofts, Educational Division/Meredith Corporation, 1970, 394 pp., $21.50
Authors: Bray Patrick F.
Published: December 2021

This new work by Dr. Ingrid Gamstorp, Head of the Department of Pediatrics of the Central Hospital, Jönköping, Sweden, joins the growing lists of texts devoted to disorders of the developing neuromuscular systems. The author's style is direct, practical, and not excessively wordy. Although she doesn't state explicitly for whom the book is written, we assume it is primarily aimed at the generalist who cares for all kinds of illness in children. Dr. Gamstorp tries to manage the author's dilemmas with more successes than failures.
Epidemiology of Mental Retardation, by Rick Heber, Ph.D. Springfield, Illinois: Charles C Thomas, 1970, 119 pp., $8.75
Authors: Zellweger Hans
Published: December 2021

Stedman's Medical Dictionary defines epidemiology as the science of epidemics and epidemic diseases, i.e., diseases attacking many people in a community simultaneously. Since mental retardation is not an epidemic disease, the reader may wonder what its epidemiology may be. On the cover one reads further: "Mental retardation is the science that crosses all specialities of medicine." Of course the author is well versed enough to define, subsequently, mental retardation as a "symptom." These then are two inaccuracies found on the cover of the booklet, although the benevolent reviewer stretches his imagination in order to recognize their true meaning.
Teen-age Medicine: The Questions Young People Ask About Their Health, by Augusta Greenblatt. New York: Cowles Book Company, Inc., 1970, 206 pp., $5.95
Authors: Masland Robert P.
Published: December 2021

A 15-year-old boy sits in his pediatrician's waiting room; magazines are available, but the titles do not interest him because they all seem to be directed to mothers with young children. Then he notes a small book entitled, Teen-Age Medicine: Questions Young People Ask About Their Health. Knowing he can't go wrong by glancing at the table of contents, he is slightly surprised to find chapters on subjects which really do interest him. "What about Mood-Changing Drugs?;" "What Should I know About Contraception?;" "How Serious is the Threat of Venereal Disease?." There are other chapters dealing with obesity, skin care, dental care, emotional problems and infectious mononucleosis; subjects which are an important part of the adolescent's world.
PATTERN OF MULTIPLE DRUG ABUSE AMONG ADOLESCENTS REFERRED BY A JUVENILE COURT
Authors: Dodson W. Edwin , Alexander Duane F. , Wright Peter F. , Wunderlich Richard A.
Published: December 2021

Thirty-five suburban youths charged with drug abuse were referred by juvenile court judges to GUIDE, an experimental program of drug education and rehabilitation staffed by volunteer physicians. The adolescents had utilized a wide range of psychoactive agents and experienced difficulties in academic and interpersonal areas. Seventeen of 35 had neuropsychiatric disorders and generally the youths lacked direction and skills to pursue goals. Interference with the developmental process of adolescence is felt to be a major detrimental effect of this pattern of multiple drug abuse.
Letterer Siwe's Disease?
Authors: Lopez Rafael , Mauger David C.
Published: December 2021

I have read with interest the article of Dr. D. C. Mauger on Letterer-Siwe's disease complicated with intravascular coagulation (Pediatrics, 47: 435, 1971). I think that the possibility of intravascular coagulation has not been proven conclusively in the absence of measurement of some key factors, especially with the degree of hepatosplenomegaly this patient presented. Though it cannot be said of every situation, in the absence of decrease factor VIII and increase fibrin split products, the diagnosis of disseminated intravascular coagulation cannot be made with certainty.
Allergy in Children, by Louis Tuft, M.D. and Harry L. Mueller, M.D. Philadelphia: W. B. Saunders Company, 1970, 561 pp., $19.50
Authors: Dees Susan C.
Published: December 2021

The authors' purpose in writing this book is to answer a need for a concise review and summary of our present knowledge of allergy in cnildren for those who treat such patients. They aim to present the generally accepted points of view; in instances of controversial opinions these are briefly documented. When these are based chiefly on clinical experience, their own conclusions are given; in instances when their own opinions differ, these are indicated in the text.
The Police and the Underprotected Child, by C. J. Flammang. Springfield, Illinois: Charles C Thomas, 1970, 310 pp., $11.75
Authors: Fontana Vincent J.
Published: December 2021

This well-organized book should prove useful to a variety of professional persons who deal with the problem of child abuse and neglect, whether they be police, social workers, lawyers, physicians, nurses, or others responsible for child care. The author gives a systematic, comprehensive coverage of child abuse and neglect as it presently exists in our society.

The role the police play in the protection of the abused child has been one of confusion. Different philosophies exist between the police and some of the medical and social agencies as to what are the responsibilities of the police to the maltreated child; this issue is dealt with in proper perspective by the author, clearly explaining the concept of protecting the child versus prosecution of the offenders.
Marijuana: The New Prohibition, by John Kaplan. New York: World Publishing Company, 1970, 387 pp., $8.50
Authors: Black Robert L.
Published: December 2021

In this comprehensive review of research and legal papers relating to marijuana, Stanford Law Professor Kaplan has exhaustively gone over almost all of the various arguments involved in the debates about this drug. A review of the chapter headings gives an indication of the comprehensiveness of his examination. They are (1) marijuana as a symbol, (2) the cost of the marijuana laws, (3) the "ordinary" effects of marijuana, (4) marijuana and aggression, (5) the dangers of marijuana use,
HEALTH MANPOWER REEXAMINED
Authors: Bergman Abraham B.
Published: December 2021

As the "health care crisis" becomes this year's "in" issue, a whole host of "solutions" are unveiled, rivalling the promotion of new model cars, breakfast cereals, and X-rated movies. Common features of these proposals are: flashy titles like "Medicredit," "Ameriplan," "HMO's," and so forth, mind-boggling complexity, benefits slanted to the advantage of the proposing groups, and emphasis on payment for services rather than on personnel to provide them. Political hoopla notwithstanding, the sad fact remains that many Americans will continue to go without needed services unless alterations are made in the supply and utilization of health manpower. New payment schemes by themselves will only increase the heat under the pressure cooker.
NURSES AND PEDIATRICIANS COLLABORATE
Authors: Connelly John P.
Published: December 2021

The Academy's Committee on Pediatric Manpower was established because of the concerns of Academy membership about the numbers of American children who were not receiving health care and the tremendous pressures for service being placed on practicing pediatricians. The Committee recognized that solutions to these problems would be complex and multifaceted. One of the solutions which it chose to pursue in some depth was that of the interprofessional care of the ambulatory pediatric patient. This concept involves what is often referred to as an "expanded" role of the nurse, working in close collaboration with the pediatrician. The concept is of equal importance to the nursing profession, a large segment of which has come to deplore the increasing separation of nurses, particularly the most highly trained nurses of the profession, from patient caretaking.
CELLULAR GROWTH DURING EARLY MALNUTRITION
Authors: Winick Myron
Published: December 2021

Dr. Mapes, members of the Academy, and quests. It is a great privilege for me to stand here as a recipient of this award and to tell you about some of the work I have been involved in during the past 6 years.

Before I begin, however, I should like publicly to thank a number of people without whose guidance or direct help none of the work would have been accomplished. My teachers have been many, but four I think have instilled in me the scientific principles and experimental training which are so necessary in any project: Samuel Z. Levine who started my pediatric training; Norman Kretchmer and Robert Greenberg, who gave me the scientific and experimental training necessary for independent investigation; and Wallace McCrory who provided the proper conditions and atmosphere in which to carry out the work.

In addition, I have had the good fortune of an association with individuals throughout the world who have contributed to these studies. Professor Julio Meneghello and his whole department at the University of Chile in Santiago, Dr. John Waterlow, and Drs. Elsie Widdowson and Richard Barnes have all provided me with materials to study, as well as ideas for me to explore. Perhaps more than any, however, I should like to thank the people in my own laboratory. These include Drs. Irving Fish, Robert Karp, Elba Velasco, and finally Pedro Rosso who was invaluable to our work in Chile and who is now continuing his work in New York. A special mention, of course, must be made of Dr. Jo Anne Brasel who has recently combined her expertise with our laboratory staff and who has been an indispensable collaborator during the past 2 years.
IMPROVED INFANT MORTALITY RATES IN A POPULATION SERVED BY A COMPREHENSIVE NEIGHBORHOOD HEALTH PROGRAM
Authors: Chabot André
Published: December 2021

The Denver Department of Health and Hospitals developed from multiple federal grants (M and I, C and Y, OEO, PHS, and Family Planning) a comprehensive community health program for the low income population of Denver. To measure the impact of this program, infant mortality rates were reviewed in the low income and nonwhite populations. Infant mortality in 25 selected low income census tracts in Denver was 34.2 per thousand live births in 1964. This decreased to 24.5 by 1968. Infant mortality of nonwhites in Denver was 41.9 in 1964 and decreased to 25.2 by 1968. This decrease in infant mortality rates in both of these populations compares very favorably with such data from other cities.