bluuebunny/crossref_metadata_2025 huggingface dataset:
LIMIT ON HOURS FOR DOCTORS DRAWS CRITICS FROM ALL SIDES
Authors: L. J. F.
Published: December 2021

Four years and nearly $1 billion after New York State adopted the nation's strictest limits on the hours worked by medical residents, it is unclear whether the changes have helped or hurt patient care, doctors and hospital administrators say.

In many hospital departments, the rules are simply ignored, meaning that residents are working well beyond the 80-hour-a-week limit imposed by the state and are potentially more vulnerable to exhaustion and mistakes.

And where they are being followed, strict enforcement of the rules is resulting in a time-clock approach under which, critics charge, residents leave in the middle of procedures or delay tests because it is time to go home.

Still others, including the author of the original regulations, argue that the rules have not gone far enough and still allow residents to continue exercising too much responsibility.

While there is little statistical scientific evidence evaluating the changes, which have cost more than $840 million so far, a few studies do exist ...

One study at New York Hospital suggests that a result of more frequent signouts may be confusion in ordering tests and procedures. The researchers compared the charts of 263 patients who were discharged from that hospital's general medicine service in October 1988, before the new rules took effect, with the charts of the same number of patients discharged from the same hospital a year later, four months after the shorter hours were instituted.

The study found virtually no differences in the medical outcomes of the cases. But the patients treated under the new rules suffered more frequent in-hospital complications and more frequent delays of tests.
TEACHER TENURE
Authors: L. J. F.
Published: December 2021

". . . a special education teacher in New York City was arrested, convicted, and sent to prison in 1990 for selling $7000 worth of cocaine to undercover police, and school officials thought it would be easy to dismiss him.

Not so. While the teacher, Mr Dubner, served his sentence in Sullivan Correctional Center in upstate New York, he collected his teacher's pay, and, after 5 years and more than $185 000 spent by the Board of Education on disciplinary proceedings, Mr Dubner has prevailed. He still has his job.

The story of New York City's failed effort to dismiss Mr Dubner underlines how difficult it has become for school boards to get rid of tenured employees, even in extreme cases."
Letter to the Editor
Authors: Vohr Betty R.
Published: December 2021

I appreciate the opportunity to respond to the article by Drs Bess and Paradise1 in the February 1994 issue of Pediatrics in which they debate the justification of the National Institutes of Health Consensus Statement recommendations for universal hearing screening using transient evoked otoacoustic emissions (TEOAE) and brainstem auditory-evoked response (BAER).2

One of the components of screening with which the authors take issue is the specificity and positive predictive value of the TEOAE/BAER screen, a two-stage screen approach.
Letter to the Editor
Authors: Koop C. Everett
Published: December 2021

As the Surgeon General of the United States in 1989, I challenged parents, physicians, state agency staff, and researchers to work together to find better ways to identify very young children with hearing impairments. With that challenge, I set a goal that by the year 2000, all children with significant hearing impairment would be identified before 12 months of age. Although it was an ambitious goal, I was optimistic that it could be accomplished. The last 5 years have demonstrated the feasibility of that goal, and it has, in fact, been accomplished by people who were ready and eager to do something toward its achievement.
Letter to the Editor
Authors: Gravel Judith S. , Diefendorf Allan O. , Matkin Noel D.
Published: December 2021

Neonatal hearing screening has come to the forefront of interest within our professional communities and among the general public, particularly over the last year. Identifying children with hearing loss at the earliest age possible, however, has been a longstanding tenet of audiologists, pediatricians, otolaryngologists, and early childhood specialists, based both on knowledge of developmental processes and abundant clinical experiences. Indeed, the identification of conditions present in early childhood that can result in long-term disabilities are critical components of current legislative (Individuals with Disabilities Education Act [IDEA], Part H Public Law 102-119 [formerly 99-457])1 and public health initiatives (Healthy People 2000).2
Letter to the Editor
Authors: Jacobs Jennifer , Gloyd Stephen S.
Published: December 2021

Reply to Dr. Layton—We agree with Dr Layton that Pediatrics should continue to look thoughtfully at studies in areas that have previously been considered without merit. It is only through rigorous, well-controlled trials that efficacy of some of these treatment modalities can be evaluated.

Reply to Drs Duggan and Kleinman—This letter raises several important points. We agree that it would have been preferable to have precise information about both the nutritional management of these children as well as the stool output in grams or milliliters per kilogram body weight.
Coagulase-Negative Staphylococcal Bacteremia Among Very Low Birth Weight Infants: Relation to Admission Illness Severity, Resource Use, and Outcome
Authors: Gray James E. , Richardson Douglas K. , McCormick Marie C. , Goldmann Donald A.
Published: December 2021

Objective. To examine the impact of admission-day illness severity on nosocomial bacteremia risk after consideration of traditional risk determinants such as birth weight and length of stay.

Methods. The hospital courses for 302 consecutive very low birth weight (less than 1500 g) infants admitted to two neonatal intensive care units were examined for the occurrence of nosocomial coagulase-negative staphylococcal bacteremia. Using both cumulative incidence and incidence density as measures of bacteremia risk, we explored the relation between illness severity (as measured by the Score for Neonatal Acute Physiology [SNAP]) and bacteremia both before and after birth weight adjustment. In addition, the effect of bacteremia on hospital resource use was estimated.

Results. Coagulase-negative staphylococcus was the most common pathogen noted in blood cultures drawn at 48 hours after admission or later. It was isolated on at least one occasion in 53 patients (cumulative incidence of 17.5 first episodes per 100 patients). These episodes occurred during 7652 days at risk, giving an incidence density of 6.9 initial bacteremias per 1000 patient-days at risk. As expected, when compared with the nonbacteremic group, bacteremic patients were of lower birth weight (888 ± 231 vs 1127 ± 258 g; P < .01) and gestational age (26.4 ± 2.1 vs 28.9 ± 2.8 weeks; P < .01). In addition, these patients were more severely ill on admission (SNAP 17.3 ± 6.5 vs 12.2 ± 5.8; P < .01). Even after birth weight stratification, the risk of bacteremia by both measures increased with higher SNAP scores. For example, among infants with birth weights greater than 1 kg, 25% of the most severely ill patients (SNAP 20 and higher) experienced at least one bacteremic episode, whereas the rates seen in infants with intermediate (SNAP 10 to 19) and low illness severity (SNAP 0 to 9) were 8.6% and 3.0%, respectively (χ2 for trend = 7.25; P < .01). Multivariate linear regression showed that bacteremia was associated with a prolongation of neonatal intensive care unit stay of 14.0 ± 4.0 days (P < .01) and an increase in hospital charges of $25 090 ± 12 051 (P < .05), even after adjustment for birth weight and admission-day SNAP.

Conclusions. Nosocomial coagulase-negative bacteremia is an important complication among very low birth weight infants. Assessment of illness severity with SNAP provides information regarding nosocomial infection risk beyond that available from birth weight alone.
Financing of Substance Abuse Treatment for Children and Adolescents
Authors:   Committee on Child Health Financing,   Committee on Substance Abuse
Published: December 2021

The American Academy of Pediatrics (AAP) recognizes the impact of substance abuse on society and particularly on infants, children, and adolescents. Policy statements and a manual published by the AAP have recently discussed the role of the pediatrician in the management of substance abuse,1,2 the identification and treatment of drug-exposed infants,3 and generic guidelines for the selection of substance abuse treatment facilities.4 Inadequate financing, however, remains a very significant impediment to the implementation of AAP policy and often has grave implications for families and children.

PROBLEMS IN FINANCING SERVICES FOR SUBSTANCE ABUSE

Private and public financing of chronic disease services, including those involved with substance abuse services are conflicting, confusing, and inadequate for children and adolescents. The following four main problems occur: 1) many children and adolescents, even if they are well-insured for other medical services, lack coverage for substance abuse services; 2) even when substance abuse coverage exists, copayments and deductibles make access difficult; 3) reimbursement often partially covers treatment but not prevention; and 4) services are not continuous or coordinated because of financing difficulties.

Patients are often treated for substance abuse in inpatient settings unnecessarily because of the limitations of financial coverage for outpatient substance abuse services.5 These limitations increase patient reliance on public financing. The provision of comprehensive services, including anticipatory guidance and prevention, risk assessment, early diagnostic evaluation, treatment, and follow-up care, is seldom consistent or continuous. As a result, health care providers are frequently pressured into recommending inappropriate levels of care based on third-party payer reimbursement considerations rather than on medical and psychosocial assessment and needs.
In-Hospital Mortality for Surgical Repair of Congenital Heart Defects: Preliminary Observations of Variation by Hospital Caseload
Authors: Jenkins Kathy J. , Newburger Jane W. , Lock James E. , Davis Roger B. , Coffman Gerald A. , Iezzoni Lisa I.
Published: December 2021

Objective. To examine the impact of hospital caseload on in-hospital mortality for pediatric congenital heart surgery.

Design. Population-based, retrospective cohort study.

Setting. Acute care hospitals in California and Massachusetts.

Patients. Children undergoing surgery for congenital heart disease, identified by the presence of procedure codes indicating surgical repair of a congenital heart defect in computerized statewide hospital discharge abstract databases. Cases were grouped into four categories based on the complexity of the procedure.

Main outcome measures. Adjusted odds ratios (OR) for in-hospital death were estimated using generalized estimating equations that account for the intra-institutional correlation among patients.

Results. A total of 2833 cases at 37 centers were identified. Compared with centers performing >300 cases per year, after controlling for patient characteristics, centers performing <10 cases per year had an OR for in-hospital death of 7.7 (95% confidence interval (CI) [1.6-37.8]); 10 to 100 cases, OR = 2.9 (95% CI [1.6-5.3]); 101 to 300 cases, OR = 3.0 (95% CI [1.8-4.9]). Independent risk factors for mortality included procedure complexity category (P < .0001), use of cardiopulmonary bypass (P < .0001), young age at surgery (P = .001), and transfer from another acute care hospital (P < .0001). Few differences were found by hospital caseload in length of stay or total hospital charges.

Conclusions. For children with a congenital heart defect who underwent surgery in California in 1988 or Massachusetts in 1989, the risk of dying in-hospital was much lower if the surgery was performed at an institution performing >300 cases annually. This study was limited by the absence of clinical detail in discharge abstract databases. If these findings are corroborated by other studies, health care delivery strategies that direct children requiring surgical correction of congenital heart defects to high-volume centers may substantially reduce overall mortality.
Health Supervision for Children With Achondroplasia
Authors:   Committee on Genetics
Published: December 2021

This set of guidelines is designed to assist the pediatrician in caring for children with achondroplasia confirmed by radiographs and physical features. Although pediatricians usually first see children with achondroplasia during infancy, occasionally they are called on to advise the pregnant woman who has been informed of the prenatal diagnosis of achondroplasia or asked to examine the newborn to help establish the diagnosis. Therefore, these guidelines offer advice for these situations as well.

Achondroplasia is the most common form of disproportionate short stature.1 The diagnosis is based on very specific features on the radiographs, which include a contracted base of the skull, a square shape to the pelvis with a small sacrosciatic notch, short pedicles of the vertebrae, rhizomelic (proximal) shortening of the long bones, trident hands, a normal length trunk, proximal femoral radiolucency, and, by mid-childhood, a characteristic chevron shape of the distal femoral epiphysis. Hypochondroplasia and thanatophoric dysplasia are part of the differential diagnosis, but achondroplasia can be distinguished from these because the changes in hypochondroplasia are milder and the changes in thanatophoric dysplasia are much more severe and invariably lethal. Achondroplasia is an autosomal dominant disorder, but approximately 75% of cases represent new dominant mutations. The gene for achondroplasia has recently been found. Achondroplasia is due to a change in the genetic information for fibroblast growth factor receptor 3.2,3 Almost all of the mutations have been found to occur in exactly the same spot. Now that the gene has been found and the mutation known, potential therapies and diagnostic methodologies are likely to be developed.
VASCULAR ENDOTHELIAL GROWTH FACTOR IN OCULAR FLUID OF PATIENTS WITH DIABETIC RETINOPATHY AND OTHER RETINAL DISORDERS
Authors: L. J. F.
Published: December 2021

Background. Retinal ischemia induces intraocular neovascularization, which often leads to glaucoma, vitreous hemorrhage, and retinal detachment, presumably by stimulating the release of angiogenic molecules. Vascular endothelial growth factor (VEGF) is an endothelial-cell-specific angiogenic factor whose production is increased by hypoxia.

Conclusions. Our data suggest that VEGF plays a major part in mediating active intraocular neovascularization in patients with ischemic retinal diseases, such as diabetic retinopathy and retinal-vein occlusion.
DOES PROGRESS DEMAND THAT SCIENTISTS NOW PUT INTERNET ADDRESSES ON ALL COMMUNICATIONS?
Authors: L. J. F.
Published: December 2021

Each of us eventually will have a unique Internet address. We owe it to ourselves and the science community to use it—as well as our mailing addresses, AIP codes, fax numbers, and phone numbers—on all correspondence, whether print or electronic. As far as "clutter" is concerned, most Internet addresses are brief enough— not much longer than an international telephone number.

...For starters, you can buy a rubber stamp or sticker to update your letterheads to include your street addresses, your phone and fax numbers, and your E-mail addresses.
Low Incidence of Helicobacter pylori Infection in Children With Recurrent Abdominal Pain in Philadelphia
Authors: Blecker Uwe , Mehta Devendra I. , Lanciers Sophie , Dahodwala Idris D. , Lebenthal Emanuel
Published: December 2021

Reports from many parts of the world show that Helicobacter pylori infection is widely distributed geographically.1 Both chronic active (antral) gastritis and H pylori colonization are common, even in an asymptomatic population2 and H pylori gastritis has been recognized as an important cause for recurrent abdominal pain (RAP) in children.3 Although the prevalence of H pylori positivity increases with age,4 an important number of relatively young children have been shown to be already infected with this bacteria.5
THE ASSAULT ON TEACHING HOSPITALS
Authors: L. J. F.
Published: December 2021

The quality of American health care—unarguably the best in the world—is under siege. Republicans released budget plans last week that would cut subsidies to teaching hospitals that train doctors and perform clinical research. Meanwhile, the private market, whose reform Congress bungled last year, has been doing the same. The two-pronged assault is alarming.

American physicians provide innovative, technically advanced care whose quality can be traced in part to generous subsidies for basic research that Congress has provided through the National Institutes for Health (NIH). The NIH estimates that the Senate budget plan could reduce these subsidies for non-AIDS research over the next seven years by as much as 25%; the cut is deeper if inflation is taken into account.

The proposed NIH cuts are easily identified and will be subject to public scrutiny. Two other threats are harder to spot.

The Federal Government, when reimbursing hospitals for treating Medicare patients, pays an average of 30% extra if treatment is provided in a teaching hospital. The extra payments cover costs associated with training doctors and translating basic research into clinical practice ... Under the GOP budgets, these payments could fall between 30 and 60%.

The other dagger aimed at teaching hospitals comes from the private sector. Private insurers have also paid more for patients treated in teaching hospitals. That practice is ending. Wielding new-found market power, health maintenance organizations and other managed-care groups are driving down hospital rates. They refuse to pay for training or research that does not directly benefit their enrollees.
ALLERGEN IMMUNOTHERAPY DECREASES INTERLEUKIN-4 PRODUCTION IN CD4+ T CELLS FROM ALLERGIC INDIVIDUALS
Authors: May Kathleen , Liu Andrew
Published: December 2021

Allergen immunotherapy results in a decrease in IL-4 production by CD4+ T cells.
AMBIENT OZONE CAUSES UPPER AIRWAYS INFLAMMATION IN CHILDREN
Authors: Greos Leon S.
Published: December 2021

Ozone at ambient concentrations initiates a reversible inflammatory response of the upper airways in school-aged children.
PROGRESSIVE BRONCHIAL OBSTRUCTION DURING THE ACUTE STAGE OF RESPIRATORY TRACT INFECTION IN ASTHMATIC CHILDREN
Authors: Cvietusa Peter
Published: December 2021

For most asthmatics respiratory pathogens will cause an exacerbation of their asthma. Progresive bronchial obstruction is inevitable in affected patients although some patients may have more severe obstruction. The time-course in milder exacerbations is uniform when left untreated by the significant addition of anti-inflammatory medicine.
INTEGRATED CARE FOR ASTHMA: A CLINICAL, SOCIAL, AND ECONOMIC EVALUATION
Authors: Bell Thomas
Published: December 2021

The authors conclude that the British Thoracic Society guidelines on asthma management, which recommend closer liaison between primary and secondary care providers, are valid.
REASSESSING THE THERAPEUTIC RANGE FOR THEOPHYLLINE ON LABORATORY REPORT FORMS: ANOTHER VIEWPOINT
Authors: Kamada Alan K.
Published: December 2021

The therapeutic utility of theophylline and the recommended range for serum concentrations are debated in a series of three editorials by noted contributors in this area. In the first, it is pointed out that the role of theophylline has evolved into an "adjunctive" therapy for asthma and chronic obstructive pulmonary disease. Serum concentrations of 10 to 15 µg/mL do not sacrifice significant clinical benefit, whereas there is increased risk for adverse effects at higher concentrations. Changing laboratry report forms to designate a lower therapeutic range of 5 to 15 µg/mL for an increased margin of safety (with >20 µg/mL continuing as the lower limit of the toxic range) is advocated and a stepwise approach for implementing this change is proposed.

The second paper supports the view that theophylline remains more important than a third- or fourth-line agent in the treatment of asthma, particularly in selected patients. A higher target serum concentration range of 10 to 15 µg/mL may be desirable in more severe asthmatics (requiring oral steroids despite treatment with inhaled steroid), those with nocturnal symptoms, acute exacerbations requiring hospitalization and mechanical ventilation, and in patients for whom this is a more economical or preferable therapy. In these patients a serum concentration of 5 µg/mL may be too low to achieve sufficient benefit. Designation of "10 to 15 µg/mL (5 to 20)" as the therapeutic range is suggested to emphasize the midrange as the target while indicating that levels between 5 and 20 µg/mL are acceptable, although not ideal from either an efficacy or safety standpoint.

In the third and final viewpoint presented, much data supporting the efficacy of theophylline in the treatment of chronic asthma and its relationship to serum concentrations are presented. Evidence for potential anti-inflammatory effects of theophylline is also reviewed. Severe toxicity, a rare event, is noted to be not a result of serum concentrations slightly above the therapeutic range, but from massive overdosage and/or drug interactions or concomitant illnesses that alter elimination of the drug. No changes in the recommended therapeutic range of theopylline, which might alter its effectiveness, are proposed. Rather, more careful use and monitoring through education of prescribers is advocated.
REDUCTION OF MATERNAL-INFANT TRANSMISSION OF HUMAN IMMUNODEFICIENCY VIRUS TYPE I WITH ZIDOVUDINE TREATMENT
Authors: Paul Mary E. , Shearer William T. , Church Joseph A.
Published: December 2021

Zidovudine, given in the regimen described above, significantly reduced the risk of maternal-infant HIV transmission in pregnant women with mildly symptomatic HIV disease and no prior treatment with antiretroviral drugs during pregnancy, with few short-term side effects of therapy.
EFFICACY OF PRIMARY CHEMOPROPHYLAXIS AGAINST PNEUMOCYSTIS CARINII PNEUMONIA DURING THE FIRST YEAR OF LIFE IN INFANTS INFECTED WITH HUMAN IMMUNODEFICIENCY VIRUS TYPE 1
Authors: Cotton Mark F.
Published: December 2021

Chemoprophylaxis is highly effective in preventing primary PCP and improves survival time in infants with HIV-1 infection.
FAMILIES AFFECTED BY PEDIATRIC ACQUIRED IMMUNODEFICIENCY SYNDROME: SOURCES OF STRESS AND COPING
Authors: Cotton Mark F.
Published: December 2021

HIV infection is unlike any disease studid to date. Its stresses can affect more than one family member, including the primary caregiver, with the threat of ill health and the ever-present possibility of dying.
Letters to the Editor
Authors: Wissow Lawrence S. , Roter Debra
Published: December 2021

Drs Nelson, Trumbull, Ravenel, and Larson raise important issues in the debate over the use of corporal punishment. They ask if sufficient justification exists to propose that parents abstain from corporal punishment, and suggest that the debate requires careful use of terminology and agreement on the outcomes to be studied. We agree with the need for a careful, dispassionate reading of the literature.

Dr Nelson suggests that experts in the field of child behavior do not support avoidance of corporal punishment.
Special Needs of Vulnerable and Underserved Populations: Models, Existing and Proposed, to Meet Them
Authors: Shirley Aaron
Published: December 2021

The rapidly changing environment in the health care industry offers great challenges, especially to those providers who traditionally have cared for vulnerable and underserved populations. These populations have special health care needs resulting from various factors, including race, geography, environment, and lack of access.

Some promising existing publicly funded models serve these populations well. Partnerships between these programs and private practitioners would be mutually beneficial to the practices and improve access to care.
Effectiveness of Individualized Developmental Care for Low-Risk Preterm Infants: Behavioral and Electrophysiologic Evidence
Authors: Buehler Deborah M. , Als Heidelise , Duffy Frank H. , McAnulty Gloria B. , Liederman Jacqueline
Published: December 2021

Objective. We assessed the effectiveness of individualized developmental support in the special care nursery for low-risk preterm infants.

Setting. A university-affiliated teaching hospital.

Participants. Twelve healthy full-term infants, and 24 low-risk preterm infants randomly assigned to a control or an experimental group.

Design. The preterm control group received standard care and the preterm experimental group received individualized developmental care at the same special care nursery.

Outcome Measures. Medical, behavioral (Assessment of Preterm Infants' Behavior and Prechtl's Neurological Examination of the Full-Term Newborn Infant), and electrophysiologic outcome (using quantitative electroencephalography with topographic mapping) of all three groups was assessed 2 weeks after the expected due date.

Results. No between-or among-group medical differences were seen for this low-risk, healthy sample. The preterm experimental group showed behavioral and electrophysiologic performances comparable to those of the full-term group, whereas the preterm control group performed significantly less well. Behavioral measures suggested significantly poorer attentional functioning for the preterm control group. Electrophysiologic results implicated the frontal lobe.

Conclusions. Individualized developmental intervention supports neurobehavioral functioning as measured at 2 weeks post-term. It appears to prevent frontal lobe and attentional difficulties in the newborn period, the possible causes of behavioral and scholastic disabilities often seen in low-risk preterm infants at later ages.
Discontinuation of Antiepileptic Drug Treatment After Two Seizure-free Years in Children With Cerebral Palsy
Authors: Delgado Mauricio R. , Riela Anthony R. , Mills Janith , Pitt Alan , Browne Richard
Published: December 2021

Objective. The risk of seizure relapse after antiepileptic drug (AED) discontinuation in children has been reported to vary between 6% and 40%. It has been suggested that neurologic deficit and mental retardation are poor prognostic factors for seizure relapse after AED discontinuation. Because epileptic children with cerebral palsy (CP) have neurologic deficits, and many have mental retardation, it is important to know their risk for seizure relapse.

Methods. AED treatment was discontinued in 65 children with CP and histories of epilepsy after 2 seizure-free years. All of the patients were followed until they had seizure relapses or for at least 2 years without seizures after AEDs were stopped. Multiple factors were analyzed for possible association with seizure relapse.

Results. Twenty-seven patients (41.5%) had seizure relapses. Patients with spastic hemiparesis had the highest relapse rate (61.5%), and those with spastic diplegia had the lowest rate (14.3%). No other factor correlated significantly with the risk of seizure relapse.

Conclusions. Discontinuation of AEDs in children with CP can, and should, be practiced when possible after patients have been seizure-free for at least 2 years. AED discontinuation in patients with spastic hemiparesis is significantly more likely to lead to seizure relapse than in patients with other CP types, but no other factor is yet known to increase the chance of relapse.
GENETIC COMPONENT AFFECTING BIRTH WEIGHT?
Authors: Student
Published: December 2021

A mother who was herself small for gestational age(SGA) has a 2.5 higher risk (relative risk) of having a SGA child compared with a mother who was not SGA. The corresponding relative risk for preterm births was 1.2, and the relative risk for low birth weight was 2.2.
Rectal Bleeding in Prader-Willi Syndrome
Authors: BHARGAVA SANGEETA A. , PUTNAM PHILIP E. , KOCOSHIS SAMUEL A. , ROWE MARC , HANCHETT JEANNE M.
Published: December 2021

Individuals with Prader-Willi syndrome manifest severe skin picking behavior. We report three patients with this syndrome in whom an extension of this behavior to rectal picking resulted in significant lower gastrointestinal bleeding and anorectal disease. The recognition of this behavior is important to avoid misdiagnosing inflammatory bowel disease in this group of patients.
Crohn's Disease Presenting as Suspected Abuse
Authors: SELLMAN S. P. B. , HUPERTZ V. F. , REECE R. M.
Published: December 2021

Recent literature on child sexual abuse has attempted to define normal and abnormal anatomic findings on examination of the anogenital region. Hobbs and Wynn, studying a population of sexually abused children, found that one third of girls and two thirds of boys show signs of anal abuse. These signs include reddening and loss of normal anal fold patterns, anal dilatation, tears, swelling of the anal margin, and skin tags. Perianal soft-tissue findings, however, may be a variation of normal. McCann et al examined 267 children who had no histories of abuse and found 41% to have perianal erythema (mixed sexes) and 11 % (all girls) to have anterior anal skin tags.
LARGER, SIMPLER TRIALS
Authors: Student
Published: December 2021

Most studies could be much larger, and so of much greater scientific value, if they had wider entrance criteria and collected ten times less data.
Salivary Testosterone Levels in Male Adolescents With Cystic Fibrosis
Authors: Boas Steven R. , Cleary Deborah A. , Lee Peter A. , Orenstein David M.
Published: December 2021

Purpose. Salivary testosterone concentrations have been used for monitoring testosterone levels in male adolescents and have been found to correlate closely with serum values. Data are lacking on such measurements in male adolescents with cystic fibrosis (CF), in which salivary gland abnormalities are commonly seen. Delayed sexual maturation occurs in many patients with CF, particularly those with severe disease. We examined the usefulness of salivary testosterone collection and measurement in male adolescents with CF.

Methods. Forty boys with CF and 35 healthy control boys participated in the study. All boys were Tanner staged and had serum and salivary testosterone concentrations measured. Testosterone assays were performed using standard radioimmunoassay techniques.

Results. The boys with CF were slightly older, lighter in body weight, and shorter. Serum and salivary testosterone concentrations were lower in the CF group than in the control group. A significant correlation was found between serum and salivary testosterone levels for boys with CF (r = .84) and for the control boys (r .86). Mean salivary testosterone increased as age progressed and as Tanner stage advanced.

Conclusions. These results demonstrate that salivary testosterone measurements correlate well with serum values in male adolescents with CF and can be used in the monitoring of pubertal status.
Faculty Development of Pediatric Practitioners: Complexities in Teaching Clinical Precepting
Authors: Roberts Kenneth B. , DeWitt Thomas G.
Published: December 2021

Community physicians should be ideal role model preceptors for residents to learn office-based primary care. These physicians are the specialists at what they do, just as the organ-based subspecialists are the experts in their field. The faculty development course we developed considered the knowledge, skills, and attitudes necessary for clinical preceptors and attempted to address potential difficulties, such as reservations practitioners might have about accepting the role.

It should be axiomatic that once the objectives are defined and are recognized to involve skills and attitudes as well as knowledge, lectures alone (although time-efficient) will not suffice: they are unlikely to change behavior. The key is practice over time, with supervision and reinforcement by respected "experts" and peers.

Faculty development for clinical precepting is complex, because clinical precepting, particularly in pediatrics, is complex. Attention to relationships and feelings (anxiety, discomfort, stress) should be built in, along with efforts to improve knowledge and skills.
Psychosocial Problems in Refugee Children Exposed to War
Authors: McCloskey Laura Ann , Southwick Karen
Published: December 2021

At any one time there are about two dozen armed conflicts throughout the world. It has been estimated that during 1993 alone violent upheavals generated about 16 million refugees worldwide. The United States has received a significant refugee population from war zones. The two largest groups of refugees entering the country since 1975 were from Southeast Asia (about 820 000) and Central America (between 800 000 and 1 900 000). Although exact statistics are unavailable, it appears that as many as half of the Central American immigrants were children.

Various studies have documented common physical health problems in refugee children entering North America. Inactive tuberculosis and hepatitis are prevalent health risks for Southeast Asian youth; intestinal parasites and respiratory tract infections (eg, otitis media) are widespread in both Southeast Asian and Latin American refugee children. Histories of malnutrition and incomplete immunizations are common.

Although physicians are well-equipped to treat the range of physical ailments of refugee children, some of the most serious symptoms are likely to be psychological. Recovery from physical deprivation appears to be more rapid and complete than recovery from emotional trauma and loss. The symptoms of posttraumatic stress disorder (PTSD), described below (Table 1), can be disabling and persistent and are often undetected by adult caretakers. Other psychological problems resulting from war-induced trauma and displacement, as well as immigration and chronic poverty, place refugee children at heightened risk.

Pediatricians are typically the first and often the only contact these mothers and children have with any form of health care or social service.
In Reply: High-frequency Oscillatory Ventilation as Rescue Therapy in Sick Preterm Neonates (≤1250 g): Outcome and Its Prediction
Authors: PARANKA MICHAEL S. , CLARK REESE H.
Published: December 2021

We appreciate the observation reported by Cheung et al, and agree with their findings. We reported similar results on survival in premature infants with pulmonary interstitial emphysema in 1986. These data show that high-frequency oscillatory ventilation (HFOV) response delineates two groups of infants with different outcomes. It is important to note that most neonates treated with HFOV have improved ventilation, but that a smaller proportion of neonates have improved oxygenation. In our experience improved oxygenation is a better predictor of outcome than improved ventilation.
Persistent Pulmonary Hypertension of the Newborn and Smoking and Aspirin and Nonsteroidal Antiinflammatory Drug Consumption During Pregnancy
Authors: Van Marter Linda J. , Leviton Alan , Allred Elizabeth N. , Pagano Marcello , Sullivan Kathleen F. , Cohen Aaron , Epstein Michael F.
Published: December 2021

Objective. Prenatal causation of persistent pulmonary hypertension of the newborn (PPHN) is suggested by a specific pattern of pulmonary vascular remodeling observed immediately after birth in some infants with fatal PPHN. The goal of this study was to determine whether PPHN is associated with fetal exposure to: (1) tobacco and marijuana smoking (ie, contributors to fetal hypoxemia), (2) consumption of aspirin and other nonsteroidal antiinflammatory drugs (ie, inhibitors of prostaglandin synthesis), and (3) cocaine use (ie, a contributor to vasospasm).

Design. Case-control interview study.

Setting. Two Harvard-affiliated newborn intensive care units.

Participants. Mothers of case infants who had PPHN or who met criteria for the referent group.

Interventions. During July 1985 through April 1989, we interviewed mothers of 103 infants with PPHN and 298 control infants. Because of potential selection bias that might result from recruiting only inborn control infants even though two-thirds of cases were outborn, separate analyses compared the 103 total and 35 inborn infants with PPHN with the 298 inborn control infants. Multivariate analyses were used to adjust for potential confounding factors, including maternal education and Medicaid health insurance (ie, two markers of socioeconomic status), other antenatal factors found to be associated with PPHN (ie, maternal urinary tract infection and diabetes mellitus), and the infant's sex.

Main Outcome Measures. Self-reported use or consumption of tobacco, marijuana, cocaine, aspirin, and other nonsteroidal antiinflammatory drugs during pregnancy.

Results. The adjusted odds ratios (and 95% confidence intervals) for maternal pregnancy exposures to the factors of principal interest among the total study population were: aspirin, 4.9 (1.6-15.3); and nonsteroidal antiinflammatory drugs, 6.2 (1.8-21.8); for the inborn group they were: aspirin, 9.6 (2.4-39.0); and nonsteroidal antiinflammatory drugs, 17.5 (4.3-71.6). Although the association between tobacco smoking during pregnancy and PPHN was elevated in univariate analyses, with odds ratios (and 95% confidence intervals) of 2.0 (1.2-3.4) and 1.3 (0.6-3.3) for total and inborn populations, respectively, the relationship was not significant after adjustment for all other factors in the final logistic regression model. Acknowledged illicit drug use was too infrequent (3.2%) to evaluate.

Conclusion. Maternal consumption of nonsteroidal antiinflammatory drugs and aspirin during pregnancy or the reasons these drugs were ingested seem to contribute to an increased risk of PPHN.
MULTIPLE BIRTHS: A WAKE-UP CALL
Authors: L. J. F.
Published: December 2021

Miss Helen can recall when the Dionne quints were born in 1934, an event as rare and heralded as the birth of a white buffalo. But today, in the United States alone, there are 42 sets of quintuplets with all members living, including the three little girls and two boys born recently at Long Island Jewish Medical Center to Pnina and Shmuel Klaver of Flatbush. Triplets are more plentiful still. About 2500 sets are born annually.

Twins and other multiples often delight their families, but they also present challenges for them and society as a whole.

Multiples are much more prone to premature birth, a situation that can produce a whopping first-year health care tab—more than $1 billion for all low birth weight multiples, 35% of it borne by Medicare and Medicaid. Birth defect rates are also elevated in multiples. The rate of cerebral palsy, for example, is six times that for singletons, according to one study. And financial and child care burdens are heavier. One side effect: studies show child abuse is more common in families of multiples.

. . . There is no data about how many multiple births are the result of fertility treatment. But it is estimated that 25% of pregnancies resulting from fertility treatment are multiple pregnancies.
Safety and Pharmacokinetics of Recombinant Human Superoxide Dismutase Administered Intratracheally to Premature Neonates With Respiratory Distress Syndrome
Authors: Rosenfeld Warren N. , Davis Jonathan M. , Parton Lance , Richter Susan E. , Price Anita , Flaster Edith , Kassem Nadim
Published: December 2021

Objective. As a first step in the evaluation of recombinant human CuZn superoxide dismutase (rhSOD) in the prevention of neonatal lung injury, safety and pharmacokinetics of intratracheally (IT) administered rhSOD were studied.

Methods. Twenty-six preterm infants weighing 750 to 1250 g with respiratory distress syndrome were studied in three sequential groups (placebo, 0.5, and 5 mg/kg). Placebo or rhSOD was administered IT 30 minutes after the first surfactant dose. Serial blood and urine studies, rhSOD levels, tracheal aspirate fluid (TAF) markers of acute inflammation, radiographs, and ultrasounds were performed over the 28-day study period.

Results. Serum SOD concentrations were similar at baseline for all three groups (geometric mean 0.2, upper-lower limit 0.1 to 0.2 µg/mL). In the 0.5-mg/kg group, levels were highest at 12 hours (geometric mean 0.7, upper-lower limit 0.5 to 0.8, µg/mL) and returned to baseline by day 3. In the 5-mg/kg group, levels were highest at 6 hours (geometric mean 3.0, upper-lower limit 2.3 to 4.0 µg/mL) and returned to baseline by day 4. Concentrations of SOD in TAF were also similar at baseline for all three groups (geometric mean 0.2, upper-lower limit 0.2 to 0.3 µg/mL). There were no significant increases in the placebo group, but levels in the 0.5-mg/kg group were highest when first sampled at 24 hours (geometric mean 1.1, upper-lower limit 0.8 to 1.4 µg/mL) and returned to baseline by day 3. In the 5-mg/kg group, levels were also highest when sampled at 24 hours (geometric mean 1.4, upper-lower limit 0.9 to 2.1 µg/mL) and returned to baseline by day 4. Urine levels were highest at 12 hours in both the 0.5-mg/kg (geometric mean 1.3, upper-lower limit 1.0 to 1.7 µg/mL) and 5-mg/kg infants (geometric mean 6.4, upper-lower limit 3.9 to 10.4 µg/mL) and decreased significantly by days 2 to 3. rhSOD activity assays (serum, TAF, and urine) demonstrated that the enzyme still possessed significant activity. No adverse effects of rhSOD were found. TAF neutrophil chemotactic activity and albumin concentrations, important acute lung injury markers, were significantly lower in the high-dose rhSOD group compared with the other groups.

Conclusions. Data suggest that a single IT dose of rhSOD results in significant increases in both concentration and activity of the antioxidant in serum, TAF, and urine for 2 to 3 days. The enzyme appears to be well tolerated, and TAF inflammatory markers are reduced after administration. This has important implications in rhSOD trials to prevent acute and chronic lung injury in preterm neonates.
Cardiac Effects of Dexamethasone in Very Low Birth Weight Infants
Authors: Bensky Andrew S. , Kothadia Jamanadas M. , Covitz Wesley
Published: December 2021

Objective. To characterize the cardiac effects of dexamethasone in very low birth weight infants.

Design. Prospective, randomized, placebo-controlled, double-blind trial. Enrolled subjects were randomized to receive either a 42-day tapering course of dexamethasone or a saline placebo. Echocardiographic measurements were obtained on days 0, 7, 14, 28, and 42.

Subjects. Thirteen infants received dexamethasone and 13 a saline placebo. The two groups were similar in birth weight, gestational age, age at enrollment, and sex/race composition.

Results. Patients receiving dexamethasone had a significantly larger increase in septal thickness on days 7, 14, and 28 and left ventricle (LV) posterior wall thickness on day 14. A significantly lower left ventricular enddiastolic dimension in the dexamethasone group was initially noted on day 7 and persisted until day 42. With the reduced left ventricular end-diastolic dimension, no significant differences in LV mass were noted, despite the increased wall thickness. No differences in LV systolic function, as assessed by area shortening, were seen. Assessment of diastolic function showed a significant increase in the atrial portion of mitral inflow in dexamethasone patients on day 14, as well as a significant prolongation in isovolumic relaxation time on days 7, 14, and 28.

Conclusions. Infants receiving dexamethasone developed evidence for impaired LV filling with a larger increase in wall thickness but no increase in LV mass, asymmetric septal hypertrophy, or augmented systolic function. This suggests that alterations in left ventricular filling play an important role in the development of hypertrophy seen with dexamethasone administration.
Cognitive Functioning and Brain Magnetic Resonance Imaging in Children With Sickle Cell Disease
Authors: Armstrong F. Daniel , Thompson Robert J. , Wang Winfred , Zimmerman Robert , Pegelow Charles H. , Miller Scott , Moser Franklin , Bello Jacqueline , Hurtig Anita ,   Kerstin Vass for the Neuropsychology Committee of the Cooperative Study of Sickle Cell Disease
Published: December 2021

Objective. Brain magnetic resonance imaging (MRI) and neuropsychological evaluations were conducted to determine whether neuroradiographic evidence of infarct in children with sickle cell disease between ages 6 and 12 years would result in impairment in cognitive and academic functioning.

Method and Design. Children enrolled in the Cooperative Study of Sickle Cell Disease were evaluated with brain MRI and neuropsychological evaluation. Completed studies were obtained for 194 children, 135 with HbSS. MRIs were categorized according to the presence of T2-weighted, high-intensity images suggestive of infarct and were further categorized on the basis of a clinical history of cerebrovascular accident (CVA). An abnormal MRI but no clinical history of CVA was classified as a silent infarct. Neuropsychological evaluations included assessment of both global intellectual functioning and specific academic and neuropsychological functions.

Results. Central nervous system (CNS) abnormalities were identified on MRI in 17.9% of the children (22.2% of children homozygous for HbS), and a clinical history of CVA (N = 9, 4.6%) was identified in only children with HbSS disease. Subsequent analyses examined only children with HbSS. Children with a history of CVA performed significantly poorer than children with silent infarcts or no MRI abnormality on most neuropsychological evaluation measures. Children with silent infarcts on MRI performed significantly poorer than children with no MRI abnormality on tests of arithmetic, vocabulary, and visual motor speed and coordination.

Conclusions. These results substantiate the importance of careful evaluation, educational planning, and medical intervention for CNS-related complications in children with sickle cell disease.