bluuebunny/crossref_metadata_2025 huggingface dataset:
Molecular recognition in bone morphogenetic protein (BMP)/receptor interaction
Authors: Sebald Walter , Nickel Joachim , Zhang Jin-Li , Mueller Thomas D.
Published: August 2004

Bone morphogenetic proteins (BMPs) and other members of the TGF-β superfamily are secreted signalling proteins determining the development, maintenance and regeneration of tissues and organs. These dimeric proteins bind, via multiple epitopes, two types of signalling receptor chains and numerous extracellular modulator proteins that stringently control their activity. Crystal structures of free ligands and of complexes with type I and type II receptor extracellular domains and with the modulator protein Noggin reveal structural epitopes that determine the affinity and specificity of the interactions. Modelling of a ternary complex BMP/(BMPR-IAEC)2/(ActR-IIEC)2suggests a mechanism of receptor activation that does not rely on direct contacts between extracellular domains of the receptors. Mutational and interaction analyses indicate that the large hydrophobic core of the interface of BMP-2 (wrist epitope) with the type I receptor does not provide a hydrophobic hot spot for binding. Instead, main chain amide and carbonyl groups that are completely buried in the contact region represent major binding determinants. The affinity between ligand and receptor chains is probably strongly increased by two-fold interactions of the dimeric ligand and receptor chains that exist as homodimers in the membrane (avidity effects). BMP muteins with disrupted epitopes for receptor chains or modulator proteins provide clues for drug design and development.
Grip Force Vectors for Varying Handle Diameters and Hand Sizes
Authors: Edgren Cally S. , Radwin Robert G. , Irwin Curtis B.
Published: August 2004

Grip force was measured along two orthogonal axes and vector summed. Sixtyone participants recruited from a manufacturing facility (29 men and 32 women) grasped instrumented cylinders (2.54, 3.81, 5.08, 6.35, and 7.62 cm diameter) using a maximal voluntary power grip. Two orthogonal force measurements relative to the third metacarpal were resolved into a magnitude and corresponding angle. On average, magnitude increased 34.8 N as handle diameter increased from 2.54 cm to 3.81 cm, and then monotonically declined 103.8 N as the handle diameter increased to 7.62 cm. The average direction monotonically decreased from 59.2° to 37.7° as handle diameter decreased from the largest to the smallest. When the diameter was smallest, the greatest force component, Fx (168.6 N), was in the direction where the fingertips opposed the palm. Conversely, when the diameter was largest, the smallest component, Fx(77.7 N), was in the same direction. These values are averaged for the left and right hand. The angle for the largest diameter increased with increasing hand size. These relationships should be useful for the design of handles that require gripping in specific directions, such as for hand tools and controls. Actual or potential applications of this research include the design of handles that require gripping in specific directions, such as for hand tools and controls, that reduce effort, and that prevent fatigue and overexertion.
Remembrance of Cases Past: Who Remembers What, When Confronting Critical Flight Events?
Authors: O'Hare David , Wiggins Mark
Published: August 2004

Recent “naturalistic” theories of decision making emphasize the role of stored prior experiences or cases as a guide to current action. However, there is little empirical evidence on the role that case-based remindings play in real-life decision making. The present study utilized a Web-based survey to collect data about the role of prior cases in pilot decision making about critical flight events. Results showed that more than half of the 1081 pilots who responded could provide details about utilizing a previous case in responding to a critical flight event. These events were most likely to involve weather or equipment failure. The cases were found to be useful in situational assessment rather than option evaluation. The use of cases increased with age and experience. Data obtained from a concurrent conventional survey showed broadly similar results. The implications of these results are that case-based remindings play an important role in expert pilot decision making and that a training system that incorporates case-based learning would be a potentially useful means of improving pilot decision making. Actual or potential applications of this research include the development of case-based training systems to enhance flight training.
Foot Shape Modeling
Authors: Luximon Ameersing , Goonetilleke Ravindra S.
Published: August 2004

This study is an attempt to show how a “standard” foot can be parameterized using foot length, foot width, foot height, and a measure of foot curvature so that foot shape can be predicted using these simple anthropometric measures. The prediction model was generated using 40 Hong Kong Chinese men, and the model was validated using a different group of 25 Hong Kong Chinese men. The results show that each individual foot shape may be predicted to a mean accuracy of 2.1 mm for the left foot and 2.4 mm for the right foot. Application of this research includes the potential design and development of custom footwear without the necessity of expensive 3-D scanning of feet.
Minimal Instrumentation May Compromise Failure Diagnosis With an Ecological Interface
Authors: Reising Dal Vernon C. , Sanderson Penelope M.
Published: August 2004

Interfaces designed according to ecological interface design (EID) display higher-order relations and properties of a work domain so that adaptive operator problem solving can be better supported under unanticipated system conditions. Previous empirical studies of EID have assumed that the raw data required to derive and communicate higher-order information would be available and reliable. The present research examines the relative advantages of an EID interface over a conventional piping-and-instrumentation diagram (PID) when instrumentation is maximally or only minimally adequate. Results show an interaction between interface and the adequacy of the instrumentation. Failure diagnosis performance with the EID interface with maximally adequate instrumentation is best overall. Performance with the EID interface drops more drastically from maximally to minimally adequate instrumentation than does performance with the PID interface, to the point where the EID interface with minimally adequate instrumentation supports nonsignificantly worse performance than does the equivalent PID interface. Actual or potential applications of this research include design of instrumentation and displays for complex industrial processes.
Engaging in Activities Involving Information Technology: Dimensions, Modes, and Flow
Authors: Montgomery Henry , Sharafi Parvaneh , Hedman Leif R.
Published: August 2004

An engagement mode involves a subject (e.g., a user of information technology, or IT) who is engaged in an activity with an object in a certain manner (the mode). The purpose of this study is to develop a general model of engagement modes that may be used for understanding how IT-related activities are shaped by properties of the user and the IT object. A questionnaire involving items on IT engagement and the experience of flow was administered to 300 participants. The results supported an engagement mode (EM) model involving 5 different engagement modes (enjoying/acceptance, ambition/curiosity, avoidance/hesitation, frustration/anxiety, and efficiency/productivity) characterized on 3 dimensions (evaluation of object, locus of control between subject and object, and intrinsic or extrinsic focus of motivation). The flow experience follows from a balance between enjoying/acceptance and efficiency/productivity propelled by ambition/curiosity. The EM model could provide a platform for considering how IT users, IT applications, and IT environments should work together to yield both enjoyment and efficiency. Actual or potential applications of this research include designing IT training programs on different levels of specificity.
Imperfect In-Vehicle Collision Avoidance Warning Systems Can Aid Drivers
Authors: Maltz Masha , Shinar David
Published: August 2004

An experiment was conducted to determine the effects of an in-vehicle collision avoidance warning system (IVCAWS) on driver performance. A driving simulator was driven by 135 licensed drivers. Of these, 120 received alerts from the IVCAWS when their headway to a lead car was less than 2s, and the other 15 (the control group) received no alerts. Drivers received varied alert interfaces: auditory, visual, and multimodal. The system had varied levels of reliability, determined by both false alarm rate and failure of the IVCAWS to alert to short headway. Results indicated that the IVCAWS led to safer (longer) headway maintenance. High false alarm rates induced drivers to slow down unnecessarily; large numbers of missed alerts did not have any significant impact on drivers. Driver acceptance of the system was mixed. Interface played a role in driver reliance on the system, with the multimodal interfaces generating least reliance. Actual or potential applications of this research include IVCAWS interface selection for greater system efficacy and user acceptance and the advisability of implementation, even of imperfect systems, for drivers who seek to maintain a safer headway.
My Mother Caused My Illness: The Story of a Survivor of Münchausen by Proxy Syndrome
Authors: Bryk Mary , Siegel Patricia T.
Published: August 2004

Objective. Münchausen by proxy syndrome (MBPS) is a form of child abuse in which a parent fabricates or produces illness in a child. Although the medical consequences of MBPS have been well described, there is no detailed published account of what it was like to grow up in a family where the mother systematically induced serious illness. This article describes one victim's childhood experiences.

Methods. The medical history was obtained from a review of the original medical records, notes from the primary physician, discussions with two physicians who provided treatment, and several meetings with the victim and the victim's therapist.

Results. This article chronicles the actual experiences of an MBPS victim through 8 years of medical abuse at the hands of her mother, reveals the victim's account of what happened to her, describes what her family was like, details the long-term consequences on emotional and physical development, identifies the factors that influence recovery, and details the impact on family relationships.

Conclusions. Child maltreatment and MBPS need to be part of the differential diagnosis when the clinical picture is atypical or does not appear medically plausible. The consequences of MBPS are psychological and physical and impact the entire family. Suggestions to assist heath care providers recognize, assess, and report cases of suspected MBPS are provided.
Safety and Pharmacokinetics of Multiple Doses of Recombinant Human CuZn Superoxide Dismutase Administered Intratracheally to Premature Neonates With Respiratory Distress Syndrome
Authors: Davis Jonathan M. , Rosenfeld Warren N. , Richter Susan E. , Parad Richard , Gewolb Ira H. , Spitzer Alan R. , Carlo Waldemar A. , Couser Robert J. , Price Anita , Flaster Edith , Kassem Nadim , Edwards Lionel , Tierney Joan , Horowitz Stuart
Published: August 2004

Objectives. To examine the safety and pharmacokinetics of multiple intratracheal (IT) doses of recombinant human CuZn superoxide dismutase (rhSOD) in premature infants with respiratory distress syndrome who are at risk for developing bronchopulmonary dysplasia (BPD).

Methods. Thirty-three infants (700 to 1300 g) were randomized and blindly received saline, 2.5 mg/kg or 5 mg/kg rhSOD IT within 2 hours of surfactant administration. Infants were treated every 48 hours (as long as endotracheal intubation was required) up to 7 doses. Serial blood and urine studies, chest radiographs, neurosonograms, SOD concentration and activity measurements, and tracheal aspirate (TA) inflammatory markers were assessed throughout the 28-day study.

Results. SOD concentrations in serum (0.1 [0.05/0.15] μg/mL–geometric mean with lower/upper confidence intervals), tracheal aspirates (TA) (0.2 [0.1/0.3] μg/mL) and urine (0.3 [0.2/0.4] μg/mL) were similar at baseline in all 3 groups and did not change significantly in the placebo group. In the rhSOD treatment groups, SOD concentrations were increased on day 3 and did not change significantly thereafter over the 14-day dosing period (also measured on days 5, 7, and 13). SOD concentrations averaged 0.4 [0.3/0.5] μg/mL in serum, 0.8 [0.6/1.2] μg/mL in TA and 1.1 [1.0/1.3] μg/mL in urine for the low-dose group and 0.6 [0.5/0.7] μg/mL in serum, 1.1 [0.9/1.5] μg/mL in TA, and 2.2 [1.6/2.9] μg/mL in urine for the high-dose group over the 14-day dosing period. Enzyme activity directly correlated with SOD concentration and rhSOD was active even when excreted in urine. TA markers of acute lung injury (neutrophil chemotactic activity, albumin concentration) were lower in the rhSOD agroups compared with placebo. No significant differences in any clinical outcome variable were noted between groups.

Conclusions. These data indicate that multiple IT doses of rhSOD increase the concentration and activity of the enzyme in serum, TA and urine, reduce TA lung injury markers and are well-tolerated. Further clinical trials examining the efficacy of rhSOD in the prevention of BPD are warranted.
Safety of a Fat-reduced Diet: The Dietary Intervention Study in Children (DISC)
Authors: Obarzanek Eva , Hunsberger Sally A. , Van Horn Linda , Hartmuller Virginia V. , Barton Bruce A. , Stevens Victor J. , Kwiterovich Peter O. , Franklin Frank A. , Kimm Sue Y. S. , Lasser Norman L. , Simons-Morton Denise G. , Lauer Ronald M.
Published: August 2004

Objective. To assess the relationship between energy intake from fat and anthropometric, biochemical, and dietary measures of nutritional adequacy and safety.

Design. Three-year longitudinal study of children participating in a randomized controlled trial; intervention and usual care group data pooled to assess effects of self-reported fat intake; longitudinal regression analyses of measurements at baseline, year 1, and year 3.

Participants. Six hundred sixty-three children (362 boys and 301 girls), 8 to 10 years of age at baseline, with elevated low-density lipoprotein cholesterol, who are participants of the Dietary Intervention Study in Children.

Measures. Energy intake from fat assessed from three 24-hour recalls at each time point was the independent variable. Outcomes were anthropometric measures (height, weight, body mass index, and sum of skinfolds), nutritional biochemical determinations (serum ferritin, zinc, retinol, albumin, β-carotene, and vitamin E, red blood cell folate, and hemoglobin), and dietary micronutrients (vitamins A, C, E, thiamin, riboflavin, niacin, vitamins B-6, B-12, folate, calcium, iron, zinc, magnesium, and phosphorus).

Results. Lower fat intake was not related to anthropometric measures or serum zinc, retinol, albumin, β-carotene, or vitamin E. Lower fat intake was related to: 1) higher levels of red blood cell folate and hemoglobin, with a trend toward higher serum ferritin; 2) higher intakes of folate, vitamin C, and vitamin A, with a trend toward higher iron intake; 3) lower intakes of calcium, zinc, magnesium, phosphorus, vitamin B-12, thiamin, niacin, and riboflavin; 4) increased risk of consuming less than two-thirds of the Recommended Dietary Allowances for calcium in girls at baseline, and zinc and vitamin E in boys and girls at all visits.

Conclusions. Lower fat intakes during puberty are nutritionally adequate for growth and for maintenance of normal levels of nutritional biochemical measures, and are associated with beneficial effects on blood folate and hemoglobin. Although lower fat diets were related to lower self-reported intakes of several nutrients, no adverse effects were observed on blood biochemical measures of nutritional status. Current public health recommendations for moderately lower fat intakes in children during puberty may be followed safely.
Mortality Within the First 2 Years in Infants Exposed to Cocaine, Opiate, or Cannabinoid During Gestation
Authors: Ostrea Enrique M. , Ostrea Anthony R. , Simpson Pippa M.
Published: August 2004

Objective. To determine the mortality rate, during the first 2 years of life, in infants who were exposed to cocaine, opiate, or cannabinoid during gestation.

Methods. For a period of 11 months, a large group of infants were enrolled and screened at birth for exposure to cocaine, opiate, or cannabinoid by meconium analysis. Death outcome, within the first 2 years after birth, was determined in this group of infants using the death registry of the Michigan Department of Public Health.

Results. A total of 2964 infants was studied. At birth, 44% of the infants tested positive for drugs: 30.5% positive for cocaine, 20.2% for opiate, and 11.4% for cannabinoids. Compared to the drug negative group, a significantly higher percentage (P < .05) of the drug positive infants had lower weight and smaller head circumference and length at birth and a higher percent of their mothers were single, multigravid, multiparous, and had little to no prenatal care. Within the first 2 years of life, 44 infants died: 26 were drug negative (15.7 deaths per 1000 live births) and 18 were drug positive (13.7 deaths per 1000 live births). The mortality rate among cocaine, opiate, or cannabinoid positive infants were 17.7, 18.4, and 8.9 per 1000 live births, respectively. Among infants with birth weight ≤2500 g, infants who were positive for both cocaine and morphine had a higher mortality rate (odds ratio = 5.9, confidence interval [CI] = 1.4 to 24) than drug negative infants. Eleven infants died from the sudden infant death syndrome (SIDS); 58% were positive for drugs, predominantly cocaine. The odds ratio for SIDS among drug positive infants was 1.5 (CI = 0.46 to 5.01) and 1.9 (CI = 0.58 to 6.2) among cocaine positive infants.

Conclusion. We conclude that prenatal drug exposure in infants, although associated with a high perinatal morbidity, is not associated with an overall increase in their mortality rate or incidence of SIDS during the first 2 years of life. However, a significantly higher mortality rate was observed among low birth weight infants (≤2500 g) who were positive for both cocaine and opiate.
Determinants of Behavior in Homeless and Low-income Housed Preschool Children
Authors: Bassuk Ellen L. , Weinreb Linda F. , Dawson Ree , Perloff Jennifer N. , Buckner John C.
Published: August 2004

Objectives. To describe the characteristics of homeless and low-income preschool-aged children, and to identify family and environmental determinants of their behavior.

Methods. An unmatched case-control design was used to recruit a sample of sheltered homeless families and a comparison group of low-income housed families who were never homeless in Worcester, Massachusetts. Seventy-seven sheltered homeless and 90 low-income housed mothers with preschool-age children were assessed using a comprehensive interview protocol. Information about mothers' housing, income, service use, par-enting practices, and children's father was obtained. Data about children's background, health, and life events were included. Standardized instruments were administered to assess mothers' mental health and their children's behavior. Comparisons of homeless and low-income housed families were used to describe the sample of 167 preschoolers. Multiple linear regression was used to examine the association of various stressors, such as homelessness, and family factors with their behavior.

Results. Although homeless preschoolers were significantly more likely to have experienced stressful life events, undergone a care and protection investigation, and been placed in foster care when compared with low income preschoolers, differences in adverse behaviors were minimal. Although homeless children scored higher than housed children on the internalizing, externalizing, and total problem score on the Child Behavior Checklist (CBCL) (52.5 vs 49.9, 54.8 vs 51.2, and 54.4 vs 51.1, respectively), approximately equal numbers of children from both groups scored in the clinical range. With regard to determinants of behavior, mothers' emotional status was one of the strongest independent predictors of negative behavioral outcomes on both subscales. Foster care placement and death of a child's friend were predictors of adverse internalizing behavioral outcomes on the CBCL. After controlling for housing status, parenting practices, child's age, child's history of physical abuse, and specific life stressors predicted adverse externalizing behavioral outcomes. For both subscales, housing status and behavior were only marginally associated in the multivariate model.

Conclusions. Both homeless and low-income children experienced significant adversity in their lives, with homeless preschool children facing more stress. However, differences in behavior as measured by the CBCL were minimal. Mothers' emotional status, in addition to various stressors, strongly predict children's negative outcomes for both CBCL subscales. These findings emphasize the importance of preventive family-oriented interventions that address the needs of preschoolers and their mothers.
Does the Supine Sleeping Position Have Any Adverse Effects on the Child?: I. Health in the First Six Months
Authors: Hunt Linda , Fleming Peter , Golding Jean ,   the ALSPAC Study Team
Published: August 2004

Objective. To assess whether the recommendations that infants sleep supine could have adverse health consequences.

Design. A prospective study of infants, delivered before, during, and after the Back to Sleep Campaign in the United Kingdom (UK), followed to 6 months of age. The children were part of the Avon Longitudinal Study of Pregnancy and Childhood (ALSPAC).

Subjects. Singletons born to mothers resident in the three former Bristol-based health districts of Avon in the period June 1991 to December 1992, and for whom questionnaires were completed on sleeping position at 4 to 6 weeks of age (n = 9777); for these infants 8524 questionnaires were also completed at 6 to 8 months of age.

Main Outcome Measures. Subjective measures of health, the presence of specific signs and symptoms, duration of sleep at night, and calling the family doctor to the home.

Results. Of 43 outcomes considered, after adjustment for 12 factors using logistic regression only 2 were associated with raised risk among infants put to sleep on their back (diaper rash and cradle cap). Infants put to sleep prone had increased risk of a number of health outcomes, including cough and possibly pyrexia.

Conclusions. There is no evidence that putting infants to sleep in the supine position results in increased morbidity, although changes in prevalence of rare disorders would not have been identified.
Predictors of Hemolytic Uremic Syndrome in Children During a Large Outbreak ofEscherichia coliO157:H7 Infections
Authors: Bell Beth P. , Griffin Patricia M. , Lozano Paula , Christie Dennis L. , Kobayashi John M. , Tarr Phillip I.
Published: August 2004

Objective. To evaluate risk factors for progression of Escherichia coli O157:H7 infection to the hemolytic uremic syndrome (HUS).

Study Design. We conducted a retrospective cohort study among 278 Washington State children <16 years old who developed symptomatic culture-confirmed E coli O157:H7 infection during a large 1993 outbreak. The purpose of the study was to determine the relative risk (RR) of developing HUS according to demographic characteristics, symptoms, laboratory test results, and medication use in the first 3 days of illness.

Results. Thirty-seven (14%) children developed HUS. In univariate analysis, no associations were observed between HUS risk and any demographic characteristic, the presence of bloody diarrhea or of fever, or medication use. In multivariate analysis, HUS risk was associated with, in the first 3 days of illness, use of antimotility agents (odds ratio [OR] = 2.9; 95% confidence interval [CI] 1.2–7.5) and, among children <5.5 years old, vomiting (OR = 4.2; 95% CI 1.4–12.7). Among the 128 children tested, those whose white blood cell (WBC) count was ≥13 000/μL in the first 3 days of illness had a 7-fold increased risk of developing HUS (RR 7.2; 95% CI 2.8–18.5). Thirteen (38%) of the 34 patients with a WBC count ≥13 000/μL developed HUS, but only 5 (5%) of the 94 children whose initial WBC count was <13 000/μL progressed to HUS. Among children who did not develop HUS, use of antimotility agents in the first 3 days of illness was associated with longer duration of bloody diarrhea.

Conclusions. Prospective studies are needed to further evaluate measures to prevent the progression of E coliO157:H7 infection to HUS and to assess further clinical and laboratory risk factors. These data argue against the use of antimotility agents in acute childhood diarrhea. Our finding that no intervention decreased HUS risk underscores the importance of preventing E coliO157:H7 infections.
School-related Issues Among HIV-Infected Children
Authors: Cohen Joyce , Reddington Catherine , Jacobs Dawn , Meade Regina , Picard Donna , Singleton Kathy , Smith Dorothy , Caldwell M. Blake , DeMaria Alfred , Hsu Ho-Wen ,   the Massachusetts Working Group on Surveillance of HIV in Children, Health Massachusetts Department of Public ,   the Centers for Disease Control and Prevention
Published: August 2004

Objective. Many children with human immunodeficiency virus (HIV) infection are surviving long enough to reach school age. This study describes issues related to school attendance and disclosure of HIV infection in a population of HIV-infected children.

Methods. A statewide pediatric HIV surveillance system was used to collect data on school-age (≥5 years old) HIV-infected children. In addition, HIV clinic nurses familiar with the child's history participated in a cross-sectional survey that collected information on school-related issues during the 1993–1994 school year.

Results. Of the 92 school-age children, only 3 were too ill to attend school. Another 5 children were home-schooled. Of the 84 who attended school outside the home, 25% had severe symptoms of HIV infection (Centers for Disease Control and Prevention [CDC] clinical category C). Absence from school ranged from less than 2 weeks during the year for half of the children (51%) to more than 8 weeks for 9 children (12%). Twenty-nine percent of the children received medication in school, usually administered by the school nurse. Over two thirds of the 50 children ages 5 to 10 years had not been told that they had HIV infection. Only 1 of the 20 children more than 10 years of age was not aware of her HIV infection. For 53% of the children attending school, no school personnel had been informed of the child's HIV infection. Administration of HIV medications at school, age of child, and treatment at one particular HIV clinic were associated with the parents' decision to inform school personnel. In the 47% of cases where the school had been informed, school nurses were most frequently notified, followed by principals and teachers.

Conclusion. Only 3% of school-age children were too ill to attend school, and almost all were enrolled in public schools. The number of HIV-infected children reaching school age will continue to grow, and public schools will bear the responsibility for educating these children. Health care providers will increasingly be called upon for guidance by both educators and families to assure that HIV-infected children receive the best education possible.
Associated Malformations in Infants With Cleft Lip and Palate: A Prospective, Population-based Study
Authors: Milerad Josef , Larson Ola , Hagberg Catharina , Ideberg Margareta
Published: August 2004

Objective. Infants with cleft lip and palate may often have other associated congenital defects although the reported incidence and the types of associated malformations vary between different studies. The purpose of this investigation was to assess the prevalence of associated malformations in a geographically defined population.

Methods. The prevalence of associated malformations in infants with clefts were collected prospectively between 1975 to 1992 on all infants born in greater Stockholm, Sweden. The patient records were also compared with data from the National Malformation Registry and other hospital records if any.

Results. Of the 616 cleft infants (367 boys, 249 girls) born during this period, 21% had associated malformations that either required follow-up or treatment. Associated malformations were more frequent in infants who had both cleft lip and palate (28%) than in infants with isolated cleft palate (22%) or infants with isolated cleft lip (8%). Malformations of the upper or lower limbs or the vertebral column were the most common other anomalies and accounted for 33% of all associated defects. Twenty-four percent of associated malformations were in the cardiovascular system and congenital heart disease was the most common isolated associated malformation. Fifteen percent of all associated malformations were multiple and they were frequently associated with mental retardation or chromosomal anomalies. Twenty-two percent of infants with associated malformations were born preterm, compared with an expected 5% incidence of preterm delivery in Sweden.

Conclusion.  A more extensive cleft seems to be associated with a higher risk for associated malformations. Although many associated congenital defects can be detected at a physical examination, the high prevalence of congenital heart disease (16 times that of general population) may justify a routine echocardiographic screening.
A Program to Immunize Hospitalized Preschool-aged Children: Evaluation and Impact
Authors: Bell Louis M. , Pritchard Michele , Anderko Rebecca , Levenson Robert
Published: August 2004

Objective. The Standards for Pediatric Immunization Practices suggest that hospitalization be viewed as an opportunity to vaccinate children. The purpose of the present study is 1) to determine the immunization status of an urban population of hospitalized preschool-aged children, 2) to study the impact of an immunization program designed to vaccinate hospitalized 0 to 2-year-old children who are underimmunized at admission, and 3) to make immunization a routine part of care for the hospitalized child.

Methods. Prospective evaluation of the immunization status of hospitalized 0 to 2-year-old residents of Philadelphia admitted to an urban children's hospital was performed. With verification of the child's immunization record through the primary care provider (PCP), needed immunizations were given and records were forwarded to notify the PCP. Educational information was provided to families and health care providers.

Main Outcome Measure. The percentage of children fully immunized on admission compared with the percentage at the time of discharge.

Results. Two thousand three hundred twenty-nine children from 0 to 2 years of age were hospitalized during the 22-month study period. Immunization records were verified in 86% (2006), requiring an average of 1.5 phone calls to the PCP. The mean patient age was 10 months. Average hospital length of stay was 4 days. On admission, 49% (980) of the 2006 study patients were fully immunized. The remaining 51% (1026) were eligible for vaccination. Immunizations were delayed greater than or equal to 2 months in 18% (355) of the children. Neither type of health care insurance nor site of primary care affected the immunization status of those evaluated at the time of admission.

Sixty-six percent (N = 674) of eligible patients received at least one vaccination before hospital discharge. Medical contraindications accounted for only 4% of the reasons eligible patients were not immunized. Of the 2006 children evaluated, the percentage of those fully vaccinated for age increased significantly from 44% on admission to 70% on discharge.

Conclusion. As a result of this program, there was a significant improvement in vaccination percentage at the time of hospital discharge in this group of urban preschool-aged children. The development of an immunization program to vaccinate hospitalized preschool children is an opportunity to immunize in the urban setting where there is a high prevalence of underimmunization.

In addition, it provides an opening for educational programs for families, nurses, and housestaff and linkage to the community PCPs.
Expenditures for Care of Children With Chronic Illnesses Enrolled in the Washington State Medicaid Program, Fiscal Year 1993
Authors: Ireys Henry T. , Anderson Gerard F. , Shaffer Tom J. , Neff John M.
Published: August 2004

Objective. We calculated expenditures for children with one of eight selected chronic health conditions who were enrolled in the Washington State Medicaid program and compared them with payments for all Medicaid-enrolled children. We examined variation in mean, median, and total expenditures and identified expenditure sources.

Methods. This study analyzed Medicaid claims data for 310 977 children aged 0 to 18 who were enrolled at any time in fiscal year 1993. Tracer conditions were used to examine expenditure variation within and between diagnostic groupings. A total of 18 233 children (5.9%) had at least one of the conditions. Expenditures were calculated based on payments made by the Medicaid program.

Results. Children with one of the eight selected conditions incurred mean expenditures of $3800, compared with $955 for all Medicaid-enrolled children. Mean payments associated with the selected conditions ranged from 2.5 times to 20 times more than payments to all children. Approximately 10% of children accounted for approximately 70% of the payments in general and in each diagnostic grouping. Variation in mean, median, and total expenditures was extensive among the conditions. For most conditions, inpatient stays accounted for the greatest proportion of expenditures; for some conditions, durable equipment, home nursing, and medication-related services accounted for substantial proportions of total expenditures.

Conclusions. Medical care for children with selected chronic health conditions is 2.5 to 20 times more expensive than children in general, depending on the condition. A relatively few children account for the majority of expenditures. Extensive variation in mean, median, and total expenditures suggests that different conditions will need to be kept distinct for purposes of establishing payment rates. Children with certain conditions are vulnerable to restrictions in specific services, depending on what restrictions are imposed by a financing program. Further analyses are needed to identify risk-adjustment strategies to support delivery of high-quality services to this population of children as they migrate into managed-care environments.
Outcome of Small-for-Gestational Age and Appropriate-for-Gestational Age Infants Born Before 27 Weeks of Gestation
Authors: Bardin Claudette , Zelkowitz Phyllis , Papageorgiou Apostolos
Published: August 2004

Objective. To evaluate the consequences of being small-for-gestational age at extremely low gestational age.

Methodology. Comparison of two historical cohorts of small-for-gestational age (SGA) and appropriate-for-gestational age (AGA) infants born between 24 and 26 6/7 weeks of gestation (gestational age estimated by early ultrasound at 16 to 18 weeks). Data were collected retrospectively on 191 successive admissions to the neonatal intensive care unit between January 1, 1983, and December 31, 1992. These included: demographic and maternal information, delivery mode and condition at birth, mortality, neonatal intensive care unit morbidities (respiratory distress syndrome, intraventricular hemorrhage, patent ductus arteriosis [PDA], chronic lung disease [CLD], retinopathy of prematurity [ROP], necrotizing enterocolitis, infection), nutrition, and length of hospitalization.

Results. Forty-one (21%) of the 191 infants were classified as SGA. Those with congenital anomalies (10% in the SGA and 2% in the AGA group) were excluded from further analysis. Despite a similar rate of respiratory distress syndrome (50%), the SGA infants had a greater rate of failure of indomethacin treatment for PDA closure (54% vs 32% for AGA), a higher risk for CLD defined as a need for supplementary oxygen at 36 weeks (65% vs 32% for AGA), a more prolonged need for oxygen supplementation and ventilatory support (94 days vs 68 days for AGA and 58 days vs 40 days for AGA, respectively). SGA infants were also at greater risk for developing severe ROP (stage ≥III) (65% vs 12% for AGA).

Conclusions.  For infants born before 27 weeks, being small-for-gestational age confers additional risks for severe morbidity, ie, PDA ligation, CLD, and ROP.
Treatment of Childhood Syndrome X
Authors: Hardin Dana S. , Hebert Jesse D. , Bayden Todd , Dehart Mary , Mazur Lynette
Published: August 2004

Objective. Hyperinsulinemia, hyperlipidemia, hypertension, and coronary artery disease comprise a quartet known as Syndrome X. This syndrome was first described in adults, but has recently been described in children and adolescents. The purpose of our study was to determine if diet or exercise is able to change the clinical profile of Syndrome X in children.

Study Design. We recruited 36 obese (% ideal body weight = 170.3 ± 31.1), children (9 to 12 yrs old) known to have high fasting cholesterol levels (177.5 ± 33.5 mg/dL). Each participated in a 6-week protocol in one of three groups: control (C), diet (D), or exercise (E). Twenty-five of the patients completed the study with full compliance. At the beginning and end of the study, we measured weight, height, blood pressure, serum insulin, and a lipid profile including: cholesterol, low density lipoprotein, high density lipoprotein (HDL), triglycerides, and apolipoprotein A (ApoA). All subject groups were similar before the study. The D group had the greatest attrition (40%) and all of the E group completed the study.

Results. After the 6-week study period, there was no significant weight loss or change in body mass index for any group. There was no significant change in blood pressure and there was no significant decline of fasting cholesterol or low density lipoprotein levels in any of the groups. HDL levels were low in all groups and did not significantly change with treatment. There was a significant decline in the triglyceride levels in both the diet and exercise groups after the study (preD = 150 ± 60; postD = 122 ± 50; preE = 165 ± 50; postE = 116 ± 39). Both the D and E groups also demonstrated a significant decrease in ApoA levels (preD = 174 ± 33; postD = 142 ± 24; preE = 200 ± 50; postE = 161 ± 23). Most impressively, fasting insulin levels significantly decreased with both diet and exercise, but did not change in controls during the 6 weeks (preC = 52 ± 19; postC = 53 ± 21; preD = 54 ± 23; postD = 15 ± 8; preE = 48 ± 21; postE = 9).

Conclusions. The findings of this study are consistent with previous studies describing the presence of Syndrome X in childhood. Both diet and exercise were effective in lowering triglyceride, ApoA levels, and insulin levels. However, due to the large rate of noncompliance in the diet group, exercise seems to be the best treatment for improvement in Syndrome X in children.
Predictors of Injury Mortality in Early Childhood
Authors: Scholer Seth J. , Mitchel Edward F. , Ray Wayne A.
Published: August 2004

Objective. To study the association between maternal/infant characteristics and mortality from injury for children 0 through 4 years of age.

Design. Historical cohort.

Setting. State of Tennessee.

Participants. Children 0 through 4 years of age at any time between January 1, 1985 and December 31, 1994. We linked birth certificates and US census data to obtain information on maternal age, race, education, neighborhood income, parity, use of prenatal care, residence location, infant's gender, and gestational age.

Main Outcome Measures. The outcome was death from injury, as determined from linked death certificates. The incidence density rates for each stratum (defined by maternal/child characteristics) were calculated by dividing the number of injury deaths by child years in the stratum. We used multivariate analysis to assess the independent contribution of each characteristic to risk of injury death.

Results. There were 1 035 504 children 0 through 4 years of age who contributed 3 414 436 child years. There were 803 deaths from injury, ie, 23.5 deaths per 100 000 child years. In the multivariate analysis, children had at least a 50% increased risk of injury mortality if they were born to a mother who had less than a high school education (relative risk [RR] = 2.88; 95% confidence interval [CI]: 1.92–4.34) compared with a college education, was <20 years of age (RR = 2.42; 95% CI: 1.76–3.31) compared with >30 years, or had >2 other children (RR = 2.97; 95% CI: 2.29–3.85) compared with no other children. Neither race nor income was significantly associated with childhood injury mortality in the multivariate analysis. Classification of children by maternal education, age, and parity defined a pronounced risk gradient in which high-risk children had an injury mortality rate >15 times that of low-risk children. The steep risk gradient was present for both infants (24-fold increase for high-risk children) and children 1 through 4 years of age (13-fold increase for high-risk children). If the injury mortality rate for all children were equal to that of the low-risk group, 614/803 (76.3%) of injury deaths would not have occurred.

Conclusions. For young children, maternal education, age, and parity are strongly and independently associated with injury mortality. These factors define a steep gradient of risk, suggesting that many injury deaths could be prevented.
Neonatal Morbidity After Elective Repeat Cesarean Section and Trial of Labor
Authors: Hook Brenda , Kiwi Robert , Amini Saeid B. , Fanaroff Avroy , Hack Maureen
Published: August 2004

Objective. To evaluate neonatal outcomes after an elective repeat cesarean section (ERCS) compared with a trial of labor (TOL).

Population and Method. All mothers who underwent previous cesarean section and delivered singleton infants at term gestation were identified during a 1-year period. Neonatal outcomes were compared between infants delivered by ERCS (n = 497) and those delivered by TOL (n = 492), and between infants delivered by a successful (n = 336) and a failed (n = 156) TOL. A cohort of mothers and their term infants delivered by routine vaginal delivery were also identified.

Results. Infants delivered by ERCS had an increased rate of transient tachypnea compared with infants born by TOL (6% vs 3%). Compared with routine vaginal deliveries, the adjusted odds ratio of developing any respiratory problem after an ERCS was 2.3 (95% confidence interval [CI]: 1.4, 3.8), and for developing transient tachypnea was 2.6 (CI: 1.5, 4.5). In addition, two infants delivered by ERCS developed respiratory distress syndrome. Infants delivered after a TOL had increased rates of suspected and proven sepsis (5% vs 2% and 1% vs 0.1%, respectively).

Compared with a successful TOL, the infants delivered by cesarean section after a failed TOL had more neonatal morbidity and had a longer hospital stay (4.8 ± 2 vs 3.1 ± 2 days). The odds ratio for developing any respiratory illness after a failed TOL was 2.1 (95% CI: 1.1, 4.1), for suspected sepsis was 4.8 (95% CI: 2.6, 9.0), and for proven sepsis was 19.3 (95% CI: 2.0, 187). Neonatal outcomes after a successful TOL were similar to routine vaginal births.

Conclusion. Infants born by ERCS are at increased risk for developing respiratory problems compared with those born by TOL. However, TOL is associated with increased rates of suspected and proven sepsis. This appears to be limited to infants delivered by cesarean section after a failed TOL.
Factors Associated With HIV Testing Among Sexually Active Adolescents: A Massachusetts Survey
Authors: Samet Jeffrey H. , Winter Michael R. , Grant Linda , Hingson Ralph
Published: August 2004

Objective. To assess sexually active adolescents' knowledge, attitudes, and behaviors associated with human immunodeficiency virus (HIV) testing and to determine the factors important in their decision to obtain voluntary HIV testing.

Design. Anonymous, random, digit-dial telephone survey undertaken in 1993.

Setting. Massachusetts households.

Participants. Adolescents, 16 to 19 years of age.

Results. Of the 567 adolescents surveyed who had sexual intercourse within the past year, 127 (22%) had received HIV testing, with 54 (10%) stating that this testing was for personal reasons. A “great deal” or “some” worry about getting HIV/acquired immunodeficiency syndrome (AIDS) was expressed by 51%, and 56% felt that it was at least a little likely that they will get AIDS. Misconceptions were common about aspects of HIV testing: 35% did not believe or did not know that the HIV test results were kept in confidence, 19% thought that AIDS testers informed partners if the results were positive, and 30% did not think that the HIV test was very accurate. Although 92% (452/490) had seen a physician in the past year, only 30% (136/452) had ever discussed AIDS with a doctor. Multivariable analysis identified five factors as independently associated with voluntary adolescent HIV testing: 1) having had more than one sexual partner within the past year [odds ratio (OR): 2.9; 95% confidence interval (CI): 1.5, 5.5]; 2) believing that condoms are only somewhat effective at preventing the spread of AIDS (OR: 2.6; 95% CI: 1.4, 4.8); 3) having discussed AIDS with a doctor (OR: 2.6; 95% CI: 1.4, 4.8); 4) not having had a teacher discuss AIDS (OR: 2.2; 95% CI: 1.2, 4.2); and 5) believing that a positive test result means one has AIDS as opposed to carrying the virus (OR: 2.0; 95% CI: 1.1, 3.7). High-risk behavior of infrequent condom use and a history of a sexually transmitted disease were not significantly associated with voluntary HIV testing.

Conclusion. Among sexually active Massachusetts adolescents, voluntary HIV testing is uncommon. Teens who have had multiple sexual partners and who do not believe condoms are effective in preventing transmission were most likely to have been tested. Issues requiring clearer communication to patients include the testing process, its availability, and confidentiality. Physicians can play an influential role in the promotion of HIV testing by discussing HIV risk behaviors with patients and offering those at risk voluntary HIV counseling and testing.