bluuebunny/crossref_metadata_2025 huggingface dataset:
Anatomic basis for labyrinthine preservation during posterior fossa acoustic tumor surgery
Authors: Kartush Jack M. , Telian Steven A. , Graham Malcolm D. , Kemink John L.
Published: October 2006

Earlier diagnosis of acoustic tumors promises to increase our opportunity to identify patients with serviceable hearing. Critical to a posterior fossa transmeatal approach for acoustic tumor resection is preservation of the underlying labyrinth. Although the labyrinth has been recognized as a limiting factor in exposure of tumor in the internal auditory canal, few reports have detailed the microscopic surgical anatomy posterior to the internal auditory canal. An anatomic study was undertaken to determine consistent relationships between critical structures within the temporal bone relevant to hearing preservation surgery. The results of this study indicate that, whereas topographic landmarks are helpful for orientation, the more consistent relationship of the labyrinth to the vestibular aqueduct and singular canal allows a more accurate localization of the underlying labyrinth. Although the vestibule frequently prevents direct visualization of the transverse crest, a dissection based upon the microsurgical anatomy will maximize visualization of the lateral fundus while preserving the integrity of the labyrinth.
Phonatory characteristics associated with bilateral diffuse polypoid degeneration
Authors: Bennett Suzanne , Bishop Sandra , Lumpkin Samuel M. M.
Published: October 2006

This paper describes the speaking fundamental frequency (SFF) and phonational range characteristics of 35 patients with bilateral diffuse polypoid degeneration. These speakers had average SFFs that were not only substantially lower than normal but also below those associated with many other types of laryngeal pathology. These patients also had phonational ranges that were substantially different from normal. Although both extremes of the pitch range were altered, the upper limit of the voice range was affected profoundly by the morphologic changes in the vocal folds that occur as a result of polypoid degeneration.
Preoperative assessment of tracheoesophageal speech
Authors: Baugh Reginald F. , Lewin Jan S. , Baker Shan R.
Published: October 2006

Air insufflation testing of tracheoesophageal (TE) puncture candidates as currently practiced lacks objectivity and relies on subjective evaluation of the sound produced. Intraesophageal pressure measurements were obtained from 21 consecutive laryngectomized patients during air insufflation by either experienced examiners or a compressed air source at 1 liter or 3 liters per minute. Postoperatively, three levels of TE speech fluency were identified. Preoperative intraesophageal pressure measurements were associated with a specific post‐TE puncture speech fluency result. Intraesophageal pressure measurements may offer a reliable objective preoperative assessment of post‐TE puncture speech fluency and identify patients who would benefit from pharyngeal myotomy at the time of TE puncture.
The syndrome of inappropriate secretion of antidiuretic hormone (siadh) following neck dissection
Authors: Wenig Barry L. , Heller Keith S.
Published: October 2006

The syndrome of inappropriate secretion of antidiuretic hormone (SIADH) is characterized by hyponatremia and urinary osmolality generally greater than serum osmolality. It is due to inappropriate water retention resulting from excessive release of antidiuretic hormone (ADH).

Seventeen patients undergoing neck dissection were studied. Six developed SIADH and two became symptomatic due to profound hyponatremia. Five of the six patients who developed SIADH had previously undergone a neck dissection and/or had received radiation therapy. A suggested pathophysiologic mechanism for this phenomenon is discussed. The syndrome can usually be prevented by fluid restriction during and after surgery.
Treatment of cervical esophageal stenosis with a long‐term indwelling prosthesis
Authors: Goode Richard L. , Burgess Lawrence P. A. , Glenn Michael G. , Schwarz Matthew B.
Published: October 2006

Intubation of the cervical esophagus with a long‐term indwelling prosthesis is described to palliate malignant strictures, and manage benign strictures in high‐risk patients. The inner cannula of a Moore design tracheostomy tube was used as the prosthesis. Over a 10‐year period, seven cases were managed in this fashion. The tube remained in place in five of seven patients for periods of 1.5 to 11 months, while a pureed or well‐masticated soft diet was tolerated. There were no major complications in this small series. Retrograde displacement was the most common minor complication; displacement did not occur in the last two cases after addition of a silicone sponge ring to the distal end of the prosthesis. Pain and discomfort was experienced in two cases, requiring temporary removal in one patient.
Function in the pharyngoesophageal segment
Authors: Mendelsohn Martyn S. , McConnel Fred M. S.
Published: October 2006

Examination of the pharyngoesophageal (PE) segment is usually limited to manometry or barium swallow. Manofluorography is a technique which allows simultaneous analysis of both manometry and videofluoroscopy of deglutition on a single video screen. Using manofluorography, the physician can see the cause of the manometric pressure waves. Understanding of the PE segment pathophysiology has been limited. Dysfunction is usually labeled as cricopharyngeal achalasia or incoordination, which may lead to cricopharyngeal myotomy. However, this approach has yielded poor results. This study demonstrates that laryngeal elevation and timing of the swallowing reflex also play an important role in controlling pressures and function in the PE segment during deglutition. These factors must also be examined in assessment of cricopharyngeal dysfunction to guide appropriate management.
Epistaxis: Medical versus surgical therapy: A comparison of efficacy, complications, and economic considerations
Authors: Schaitkin Barry , Strauss Melvin , Houck John R.
Published: October 2006

A retrospective review of 4 years experience with over 32 epistaxis patients requiring hospitalization and using a standard medical or surgical therapy for control is presented. Medical therapy included the use of anterior nasal packing alone or in association with intranasal and nasopharyngeal balloon tamponade. Surgical therapy, for the most part, consisted of ethmoid and/or internal maxillary artery ligations.

Most patients were treated initially with packing and balloons. Fifty‐two percent of the group failed this therapy and required ligations for control. The patients who did not come to operation had fewer complications, a shorter average hospital stay, and lower average cost of hospitalization without increased risk of future epistaxis. An analysis is made comparing the results, complications, and financial implications of these two approaches.
Surgical complications of bedside tracheotomy in an otolaryngology residency program
Authors: Goldstein Steven I. , Breda Stephen D. , Schneider Kenneth L.
Published: October 2006

A prospective analysis of 124 consecutive adult patients undergoing tracheotomy was performed to examine the incidence of resulting complications. All tracheotomies were performed by a junior otolaryngology resident under the supervision of a member of the attending staff or a chief resident. The vast majority were performed at the bedside in an intensive care unit. The complications were divided into two groups: early (within 2 days) and late (2 to 14 days). Seven patients had complications directly related to tracheotomy. Four of these complications occurred in three patients and were considered significant. There were no mortalities. Despite the fact that our tracheotomies were routinely performed by residents at the bedside, our complication rate was comparable to those reported from other centers. We believe that bedside tracheotomy, properly supervised and performed, is a safe procedure.
The use of sialodochoplasty in the treatment of benign inflammatory obstructive submandibular gland disease
Authors: Rontal Michael , Rontal Eugene
Published: October 2006

One of the most common causes of submandibular gland enlargement is benign inflammatory disease. The usual cause is ductal outflow obstruction due to either a calculus or stenosis allowing stasis and retrograde movement of the saliva into the acinar structures leading to an inflammatory response and gland enlargement.

Faced with a submandibular mass, a work‐up that will rule out neoplastic causes of submandibular enlargement is instituted. This includes clinical assessment, probing of the gland, radiocontrast sialography, and CT scanning.

The treatment should reflect the obstructive nature of the disease. Plastic reconstruction of the duct allows the removal of calculi, shortening of the duct, and enlargement of the outflow opening preventing recurrence and allowing healing of the gland. The procedure is performed intraorally as an outpatient, does not disrupt oral functioning, or subject the patient to the risks of gland removal or loss of that organ's function.

Our experience with 27 patients over a 7‐year period is presented with a detailed description of the technique and an analysis of the results. The procedure was successful in 22 of the 27 patients.
Primary lymphoma in the salivary glands: Report of five cases and review of the literature
Authors: Shikhani Alain , Lenhard Raymond , Samara Milhem , Salem Philip , Allam Charles
Published: October 2006

The finding of a lymphoma in a major salivary gland could mean one of two things: either it is part of a disseminated process, or it is the first clinicopathologic evidence of lymphoma. In the latter instance, whether the disease originated in the glandular stroma itself or in a paraglandular lymph node and then invaded the stroma, the lymphoma is defined as primary, as long as there is no detectable disease outside the salivary gland. Five cases of primary salivary gland lymphomas are described. All had a complete clinical staging including chest x‐ray, bilateral bone marrow biopsy, liver‐spleen scan, bilateral pedal lymphangiography and/or abdominal CT scan. There was no evidence of lymphoma outside the gland in any of the patients described; hence, these can be labeled as primary lymphomas of the salivary gland. Review of the literature suggests that this presentation of the disease is extremely rare. Although 324 cases of salivary gland lymphomas have been described in the literature, only six may be considered primary by our criteria. The remaining patients were either not adequately staged or had documented evidence of disease elsewhere at the time of diagnosis. The diagnosis of primary salivary gland lymphoma should not be made unless complete staging is performed.
The pattern and stability of postmeningitic hearing loss in children
Authors: Brookhouser Patrick E. , Auslander Martha C. , Meskan Mary E.
Published: October 2006

Following meningitis, 280 children (168 boys, 112 girls) had audiological assessment, and 87 (31%) were initially found to have a sensorineural hearing loss in one or both ears. Twenty‐three children were followed elsewhere. Of 64 children followed for an average of 3.46 years, 55 (86%) exhibited stable auditory thresholds over time, most commonly (24) bilateral, profound/anacusic losses. One moderate and four severe losses were identified, but no bilateral, mild losses. Nineteen children had asymmetric losses with varied audiometric configurations. Seven children presented with a unilateral hearing loss, again with a range of configurations. Auditory thresholds changed over time in nine children, either improving, declining, or fluctuating, over a variable interval ranging from 1 month to 12 years.
Congenital cholesteatomas in children: An embryologic correlation
Authors: Levenson Mark J. , Michaels Leslie , Parisier Simon C. , Juarbe Charles
Published: October 2006

The clinical findings in 37 children with congenital cholesteatoma of the middle ear, 17 of which have not been previously reported, are presented. Clinical findings and surgical observations are correlated with recent developmental studies. It is hypothesized that congenital cholesteatoma may originate from an epidermoid formation, which has been identified in the anterior superior lateral tympanic cavity adjacent to the anterior annulus during fetal development, and which normally is present early in development, involuting by 33 weeks' gestation. It is proposed that the epidermoid formation may not always involute, and could serve as an embryologic anlage of congenital cholesteatomas.
Esophageal web in plummer‐vinson syndrome
Authors: Okamura Hiroshi , Tsutsumi Shoichiro , Inaki Shoko , Mori Toshihiro
Published: October 2006

In Plummer‐Vinson syndrome, esophagography often reveals a web at the anterior wall of the cervical esophagus. The pathogenesis of the esophageal web and the cause of dysphagia in this syndrome were investigated radiographically, endoscopically, manometrically, and histologically. It was considered that the web seen in the esophagogram may have been formed due to the restriction of dilation of the esophageal wall, which results from repetitive inflammation and the subsequent healing process. Dysphagia in this syndrome may be explained by a decrease in swallowing power. Iron deficiency anemia may play the main role in the above histological changes and the resulting decrease in swallowing power.
Binaural cochlear implantation: Comparison of 3m/house and nucleus 22 devices with evidence of sensory integration
Authors: Balkany Thomas , Boggess William , Dinner Bernice
Published: October 2006

Direct comparison of the efficacy of cochlear implant designs has been difficult for several reasons. There have been wide variations in patients implanted and many differences in testing protocols for each device. In most instances, even a single patient may have unequal degrees of pathology and duration of deafness in the two ears.

Implantation of a 3M/House device in the left ear and a Nucleus 22 device in the right ear of a 55‐year‐old woman, deafened to a similar degree and simultaneously in both ears by streptomycin, allows an opportunity to compare function under presumably similar circumstances.

The Nucleus 22 cochlear implant was superior in this case in providing speech discrimination. Perhaps of greater interest, however, is evidence of a binaural effect. Presumably, central integration of sensory stimuli presented through two dissimilar processing strategies resulted in enhanced function on certain measures.
Surgical treatment of pharyngoesophageal spasm
Authors: Baugh Reginald F. , Baker Shan R. , Lewin Jan S.
Published: October 2006

The clinical course of 17 laryngectomees with pharyngoesophageal spasm who underwent pharyngeal myotomy was studied to determine clinical response and complications. The influence of speech therapy on the development of volitional control of pharyngoesophageal spasm, tracheoesophageal speech fluency, and the efficacy and complications of surgical treatment for pharyngoesophageal spasm were assessed. Volitional control of tracheoesophageal speech was never achieved. Ninety‐four percent of the patients (16/17) were successfully rehabilitated following surgical therapy. The complications following pharyngeal myotomy were acceptable.
Long‐term follow‐up and recent observations on 305 cases of orbital decompression for dysthyroid orbitopathy
Authors: Warren J. Douglas , Spector J. Gershon , Burde Ronald
Published: October 2006

Dysthyroid exophthalmopathy (orbitopathy) results from an enlargement of extraglobal orbital structures, producing ocular proptosis, optic nerve compression, and corneal exposure. Treatment with corticosteroids and radiation may be beneficial; refractory cases require surgical decompression of the orbit. Transantral orbital decompression was described by Walsh and Ogura and has been performed in over 350 patients at this institution. A review of 305 patients with long‐term follow‐up was performed. Visual acuity improved or was maintained ut preoperative levels in over 95% of the patients, with ocular recession ranging from 1 to 12 mm (average: 4 mm). Postoperative ocular balance of relative exophthalmos was to within 1 mm in 76% of the patients and to within 2 mm in approximately 90% of the patients. Normal postoperative extraocular muscle balance was present in 99 patients. Immediate postoperative diplopia was noted in 206 patients. Long‐term follow‐up revealed that in 137 of these patients, diplopia resolved or responded to conservative management. Extraocular muscle surgery was required for correction in 69 patients. Twenty‐seven patients had postoperative complications. These included 16 patients with hypesthesia of the infraorbital nerve, 5 patients with sinusitis, 3 patients who had incomplete decompression, 2 patients with oral antral fistulae, and 1 patient who had CSF rhinorrhea. Five patients, despite surgery, radiation, and steroid therapy progressed to blindness. We conclude that this procedure is effective and carries few complications. Orbital imaging, using computed tomography or magnetic resonance sequence with reconstructive capabilities, permits early diagnosis and treatment of dysthyroid compression optic neuropathy.
Chronic sinusitis and woodworking as risk factors for cancer of the maxillary sinus in Northeast Japan
Authors: Shimizu Hiroyuki , Hisamichi Shigeru , Hozawa Jiro , Saito Hisaki , Murai Kazuo , Hirata Hideto , Takasaka Tomonori , Togawa Kiyoshi , Konno Akiyoshi , Kimura Yo , Kikuchi Akira , Ohkouchi Yukio , Ohtani Iwao
Published: October 2006

In the period 1983 to 1985, 66 patients presented to six Japanese university hospitals with squamous cell carcinoma of the maxillary sinus. Using self‐administered questionnaires, a case‐control study was conducted to examine history of nasal diseases, occupational exposures, and other possible risk factors for this disease. For each patient, two controls were selected from the general population, matched to the patient by sex, age (± 5 years), and district of residence. A history of chronic sinusitis was associated with a 2.3‐fold increase in risk (p = 0.05). A high relative risk was also observed in males with an occupational history of woodworking or joinery, particularly when these jobs involved sanding or lathing practices (RR = 7.5, p = 0.02). No association between cigarette smoking and maxillary sinus cancer was observed in this study and no evidence was found that indoor air pollution in the home is involved in cancer development.
Usher syndrome: Clinical findings and gene localization studies
Authors: Kimberling William J. , Davenport Sandra L. H. , Priluck Ira , White Valorie , Biscone‐Halterman Karen , Brookhouser Patrick E. , Möller Claes G. , Lund Gunnar , Grissom Timothy J. , Weston Michael D.
Published: October 2006

The issue of genetic heterogeneity is a critical problem in the localization of the gene(s) for Usher syndrome. Based on the data obtained on families studied to date, the differences between type I and type II Usher syndrome appear quite distinct with regard to auditory and vestibular function. Although the majority of families can be confidently diagnosed as typical type I or type II, clinical investigations revealed four families with findings that did not fit into either of the two more common subtypes. These findings emphasize the critical importance of an indepth clinical analysis concomitant with the linkage investigation to assure accurate subtyping of Usher syndrome. Based on an analysis of only those families with definite type I or type II Usher syndrome, approximately 17% of the genome can be excluded as a potential site of the gene for type I, and 14% can be excluded as the site for the type II gene. This study will continue until the Usher gene(s) is successfully localized.
Usher syndrome: An otoneurologic study
Authors: Möller Claes G. , ödkvist Lars M. , Kimberling William J. , Davenport Sandra L. H. , Priluck Ira , White Valorie , Biscone‐Halterman Karen , Brookhouser Patrick E. , Lund Gunnar , Grissom Timothy J.
Published: October 2006

Usher syndrome is an autosomal recessive disorder characterized by severe hearing loss or deafness and retinitis pigmentosa. Eleven families with 25 affected members were studied. The test battery included genetic studies, clinical examination, audiological, ophthalmologic, and otoneurological tests, and magnetic resonance imaging. Sixteen affected persons had profound hearing loss or were considered anacusic, with absent bilateral vestibular responses. These patients had varying degrees of retinitis pigmentosa. These 16 patients were considered to have type I Usher syndrome. Nine persons were diagnosed as Usher type II with a moderate to profound hearing loss, normal vestibular function, and retinitis pigmentosa of varying degree. Magnetic resonance imaging was normal in all cases. Otoneurological tests indicated no central nervous system disturbances. The conclusion is that hearing loss and balance problems in Usher syndrome are due to inner ear damage with no evidence of central nervous system disturbances. Furthermore, the ataxia seen in Usher type I is due to a combination of retinitis pigmentosa and bilateral peripheral vestibular deficiency.
The firing properties of second‐order vestibular neurons in correlation with the far‐field recorded vestibular‐evoked response
Authors: Elidan Josef , Langhofer Laurn , Honrubia Vicente
Published: October 2006

Action potentials of the second‐order vestibular neurons of ten cats were recorded, both in rest and responding to sinusoidal and intense impulse acceleration stimuli. The data were compared with the far‐field recorded vestibular‐evoked response induced by the same impulse stimuli. It was found that the irregular (kinetic) neurons, which had a phase lead relative to head velocity, were capable of responding to these impulses with a latency as short as 3.5 msec after the start of head acceleration. It is assumed, therefore, that these neurons are the generators of the second wave of the vestibular‐evoked response, having a similar latency. A high correlation was found between the latency of the first peak in the poststimulus time histogram in response to acceleration impulses and the phase of the response to sinusoidal rotations. The regular (tonic) vestibular neurons did not respond to acceleration impulses and probably did not contribute to the vestibular‐evoked response.
Habitual Levels of Physical Activity Influence Bone Mass in 11-Year-Old Children From the United Kingdom: Findings From a Large Population-Based Cohort
Authors: Tobias Jon H , Steer Colin D , Mattocks Calum G , Riddoch Chris , Ness Andy R
Published: October 2006

We examined the influence of habitual levels of physical activity on bone mass in childhood by studying the relationship between accelerometer recordings and DXA parameters in 4457 11-year-old children. Physical activity was positively related to both BMD and bone size in fully adjusted models. However, further exploration revealed that this effect on bone size was modified by fat mass.

Introduction: Exercise interventions have been reported to increase bone mass in children, but it is unclear whether levels of habitual physical activity also influence skeletal development.

Materials and Methods: We used multivariable linear regression to analyze associations between amount of moderate and vigorous physical activity (MVPA), derived from accelerometer recordings for a minimum of 3 days, and parameters obtained from total body DXA scans in 4457 11-year-old boys and girls from the Avon Longitudinal Study of Parents and Children. The influence of different activity intensities was also studied by stratification based on lower and higher accelerometer cut-points for moderate (3600 counts/minute) and vigorous (6200 counts/minute) activity, respectively.

Results: MVPA was positively associated with lower limb BMD and BMC adjusted for bone area (aBMC; p < 0.001, adjusted for age, sex, socio-economic factors, and height, with or without additional adjustment for lean and fat mass). MVPA was inversely related to lower limb bone area after adjusting for height and lean mass (p = 0.01), whereas a positive association was observed when fat mass was also adjusted for (p < 0.001). Lower limb BMC was positively related to MVPA after adjusting for height and lean and fat mass (p < 0.001), whereas little relationship was observed after adjusting for height and lean mass alone (p = 0.1). On multivariable regression analysis using the fully adjusted model, moderate activity exerted a stronger influence on lower limb BMC compared with light activity (light activity: 2.9 [1.2–4.7, p = 0.001]; moderate activity: 13.1 [10.6–15.5, p < 0.001]; regression coefficients with 95% confidence intervals and p values).

Conclusions: Habitual levels of physical activity in 11-year-old children are related to bone size and BMD, with moderate activity exerting the strongest influence. The effect on bone size (as reflected by DXA-based measures of bone area) was modified by adjustment for fat mass, such that decreased fat mass, which is associated with higher levels of physical activity, acts to reduce bone size and thereby counteract the tendency for physical activity to increase bone mass.
Co-Treatment of PTH With Osteoprotegerin or Alendronate Increases Its Anabolic Effect on the Skeleton of Oophorectomized Mice
Authors: Samadfam Rana , Xia Qingwen , Goltzman David
Published: October 2006

We examined the effects of 60 days of co-treatment of PTH with either OPG or alendronate in oophorectomized mice. Compared with PTH alone, co-treatment of PTH with either of these two mechanistically distinct anti-catabolics improved bone volume, mechanical strength, and appendicular and axial mineralization and prolonged the beneficial effect of PTH on BMD.

Introduction: Conflicting evidence exists as to whether the anabolic effect of PTH is inhibited by the action of anti-catabolics. To examine this issue, we assessed the effects of alendronate and osteoprotegerin (OPG), two anti-catabolics with different modes of action, on the anabolic activity of PTH(1-34) in the skeleton of 4-month-old oophorectomized mice.

Materials and Methods: Mice treated with vehicle alone (PBS), alendronate alone (100 μg/kg/week), OPG alone (10 mg/kg twice a week), or PTH alone (80 μg/kg/day) were compared with each other and with animals administered PTH plus alendronate or PTH plus OPG. We assessed lumbar spine and femoral BMD at 0, 30, and 60 days. Contact radiography, histology, and histomorphometry, three-point bending assay of the femur, and serum osteocalcin and TRACP5b assays were performed at 2 months.

Results: Although alendronate and OPG each suppressed bone turnover, at the doses used, this was more profound with OPG. Increases in lumbar spine and femoral BMD and in trabecular bone volume were at least as great with OPG as with alendronate, and mechanical indices of femoral bone strength improved only with OPG. Both produced a plateau in spine and femoral BMD increases by 30 days. Co-treatment of PTH with each anti-catabolic produced additive increases in BMD in the femur and supra-additive increases in the lumbar spine with no plateau effects. Neither anti-catabolic impeded the PTH-induced increase in bone volume or the increase in mechanical strength of the femur.

Conclusions: These studies show that the highly potent anti-catabolic OPG can produce dramatic increases in BMD and bone strength; that the temporal pattern of activity of bone formation and resorption modulators may have major influence on net skeletal accrual; and that, depending on timing, inhibition of osteoclastic activity may markedly augment the anabolic action of PTH.
Predictors of Spontaneous Closure of Isolated Secundum Atrial Septal Defect in Children: A Longitudinal Study
Authors: Hanslik Andreas , Pospisil Ulrich , Salzer-Muhar Ulrike , Greber-Platzer Susanne , Male Christoph
Published: October 2006

OBJECTIVES. The goals were to assess the frequency of spontaneous closure of isolated secundum atrial septal defect in children and to identify predictors of spontaneous atrial septal defect closure.

METHODS. A retrospective cohort study was performed in a tertiary care pediatric cardiology center. Consecutive patients (n = 200) diagnosed as having isolated atrial septal defects (no multiple or fenestrated atrial septal defects, no additional congenital heart disease, and no syndromes) were monitored for >6 months with serial 2-dimensional echocardiography, according to a standardized protocol.

RESULTS. The median age at diagnosis was 5 months (minimum: 0 months; maximum: 13.9 years). The atrial septal defect diameter at diagnosis was 4 to 5 mm in 40% of cases, 6 to 7 mm in 28% of cases, 8 to 10 mm in 21% of cases, and >10 mm in 11% of cases. The median age at the final follow-up evaluation was 4.5 years (range: 6.8 months to 16.2 years). Thirty-four percent of atrial septal defects showed spontaneous closure, and 28% decreased to a diameter of ≤3 mm. Logistic regression analysis revealed atrial septal defect diameter and age at diagnosis as independent predictors of spontaneous closure or regression to ≤3-mm defect size. Of atrial septal defects with a diameter of 4 to 5 mm at diagnosis, 56% showed spontaneous closure, 30% regressed to a diameter of ≤3 mm, and none required surgical closure. Of atrial septal defects with a diameter of >10 mm at diagnosis, none closed spontaneously, whereas 77% required surgical or device closure. Gender and observation time were not associated with spontaneous atrial septal defect closure or regression to ≤3 mm.

CONCLUSIONS. In the present study population of children with atrial septal defects, 62% showed spontaneous closure (34%) or regression to ≤3 mm (28%). Initial atrial septal defect diameter was the main predictor of spontaneous closure.
Report of the Tennessee Task Force on Screening Newborn Infants for Critical Congenital Heart Disease
Authors: Liske Michael R. , Greeley Christopher S. , Law David J. , Reich Jonathan D. , Morrow William R. , Baldwin H. Scott , Graham Thomas P. , Strauss Arnold W. , Kavanaugh-McHugh Ann L. , Walsh William F.
Published: October 2006

A member of the Tennessee state legislature recently proposed a bill that would mandate all newborn infants to undergo pulse oximetry screening for the purpose of identifying those with critical structural heart disease before discharge home. The Tennessee Task Force on Screening Newborn Infants for Critical Congenital Heart Defects was convened on September 29, 2005. This group reviewed the current medical literature on this topic, as well as data obtained from the Tennessee Department of Health, and debated the merits and potential detriments of a statewide screening program. The estimated incidence of critical congenital heart disease is 170 in 100000 live births, and of those, 60 in 100000 infants have ductal-dependent left-sided obstructive lesions with the potential of presentation by shock or death if the diagnosis is missed. Of the latter group, the diagnosis is missed in ∼9 in 100 000 by fetal ultrasound assessment and discharge examination and might be identified by a screening program. Identification of the missed diagnosis in these infants before discharge could spare many of them death or neurologic sequelae. Four major studies using pulse oximetry screening were analyzed, and when data were restricted to critical left-sided obstructive lesions, sensitivity values of 0% to 50% and false-positive rates of between 0.01% and 12% were found in asymptomatic populations. Because of this variability and other considerations, a meaningful cost/benefit analysis could not be performed. It was the consensus of the task force to provide a recommendation to the legislature that mandatory screening not be implemented at this time. In addition, we determined that a very large, prospective, perhaps multistate study is needed to define the sensitivity and false-positive rates of lower-limb pulse oximetry screening in the asymptomatic newborn population and that there needs to be continued partnering between the medical community, parents, and local, state, and national governments in decisions regarding mandated medical care.
Assessing Postoperative Pain in Neonates: A Multicenter Observational Study
Authors: Taylor Bonnie J. , Robbins James M. , Gold Jeffrey I. , Logsdon Tina R. , Bird T. M. , Anand K. J. S.
Published: October 2006

OBJECTIVE. A multicenter observational study was conducted to evaluate the practices of postoperative pain assessment and management in neonates to identify specific targets for improvement in clinical practice.

METHODS. Ten participating NICUs collected data for the 72 hours after a surgical operation on 25 consecutive neonates (N = 250), including demographics, principal diagnoses, operative procedure, other painful procedures, pain assessments, interventions (pharmacologic and nonpharmacologic), and adverse events in neonates who underwent minor and major surgery. Descriptive and logistic-regression analyses were performed by using SPSS and Stata.

RESULTS. The neonates studied had a birth weight of 2.4 ± 1.0 kg (mean ± SD) and gestational age of 36 ± 4.3 weeks; 57% were male, and length of hospital stay was 23.5 ± 30.0 days. Participating hospitals used 7 different numeric pain scales, with nursing pain assessments documented for 88% (n = 220) of the patients and physician pain assessments documented for 9% (n = 23) of the patients. Opioids (84% vs 60%) and benzodiazepines (24% vs 11%) were used more commonly after major surgery than minor surgery, and a small proportion (7% major surgery, 12% minor surgery) received no analgesia. Logistic-regression analyses showed that physician pain assessment was the only significant predictor of postsurgical analgesic use, whereas major surgery and postnatal age in days did not seem to contribute. Physician pain assessment was documented for 23 patients; 22 of these received postoperative analgesia.

CONCLUSIONS. Documentation of postoperative pain assessment and management in neonates was extremely variable among the participating hospitals. Pain assessment by physicians must be emphasized, in addition to developing evidence-based guidelines for postoperative care and educating professional staff to improve postoperative pain control in neonates.
A Comparison of Health Care Utilization and Costs of Children With and Without Autism Spectrum Disorders in a Large Group-Model Health Plan
Authors: Croen Lisa A. , Najjar Daniel V. , Ray G. Thomas , Lotspeich Linda , Bernal Pilar
Published: October 2006

OBJECTIVE. Data on the current costs of medical services for children with autism spectrum disorders are lacking. Our purpose for this study was to compare health care utilization and costs of children with and without autism spectrum disorders in the same health plan.

PATIENTS AND METHODS. Participants included all 2- to 18-year-old children with autism spectrum disorders (n = 3053) and a random sample of children without autism spectrum disorders (n = 30529) who were continuously enrolled in the Kaiser Permanente Medical Care Program in northern California between July 1, 2003, and June 30, 2004. Data on health care utilization and costs were derived from health plan administrative databases.

MAIN OUTCOME MEASURES. Outcome measures included mean annual utilization and costs of health services per child.

RESULTS. Children with autism spectrum disorders had a higher annual mean number of total clinic (5.6 vs 2.8), pediatric (2.3 vs 1.6), and psychiatric (2.2 vs 0.3) outpatient visits. A higher percentage of children with autism spectrum disorders experienced inpatient (3% vs 1%) and outpatient (5% vs 2%) hospitalizations. Children with autism spectrum disorders were nearly 9 times more likely to use psychotherapeutic medications and twice as likely to use gastrointestinal agents than children without autism spectrum disorders. Mean annual member costs for hospitalizations ($550 vs $208), clinic visits ($1373 vs $540), and prescription medications ($724 vs $96) were more than double for children with autism spectrum disorders compared with children without autism spectrum disorders. The mean annual age- and gender-adjusted total cost per member was more than threefold higher for children with autism spectrum disorders ($2757 vs $892). Among the subgroup of children with other psychiatric conditions, total mean annual costs were 45% higher for children with autism spectrum disorders compared with children without autism spectrum disorders; excess costs were largely explained by the increased use of psychotherapeutic medications.

CONCLUSIONS. The utilization and costs of health care are substantially higher for children with autism spectrum disorders compared with children without autism spectrum disorders. Research is needed to evaluate the impact of improvements in the management of children with autism spectrum disorders on health care utilization and costs.
Multicenter Surveillance of Invasive Meningococcal Infections in Children
Authors: Kaplan Sheldon L. , Schutze Gordon E. , Leake John A.D. , Barson William J. , Halasa Natasha B. , Byington Carrie L. , Woods Charles R. , Tan Tina Q. , Hoffman Jill A. , Wald Ellen R. , Edwards Kathryn M. , Mason Edward O.
Published: October 2006

OBJECTIVES. Meningococcal disease continues to result in substantial morbidity and mortality in children, but there is limited recent surveillance information regarding serogroup distribution and outcome in children in the United States. The objective of this study was to collect demographic, clinical, laboratory, and outcome information for infants and children who had Neisseria meningitidis infections of various serogroups and were cared for in 10 pediatric hospitals.

METHODS. Investigators at each of the participating hospitals identified children with meningococcal infections and collected demographic and clinical information using a standard data form. Meningococcal isolates were sent to a central laboratory for serogrouping by slide agglutination and penicillin susceptibility.

RESULTS. From January 1, 2001, through March 15, 2005, 159 episodes of systemic meningococcal infections were detected. The greatest numbers of children were younger than 12 months (n = 41) or were 12 to 24 months of age (n = 22). Meningitis was the most common clinical manifestation of disease accounting for 112 (70%) cases; 43 (27%) children had bacteremia only. Children who were younger than 5 years (17 of 102) were significantly less likely to require mechanical ventilation than children who were 5 to 10 years of age (12 of 24) or children who were older than 10 years (13 of 33). Overall, 55 (44%) isolates were serogroup B, 32 (26%) were serogroup C, and 27 (22%) were serogroup Y. All but 1 isolate (intermediate) were susceptible to penicillin. The overall mortality rate was 8% (13 of 159) but was greater for children who were ≥11 years of age (7 [21.2%] of 33) than for children who were younger than 11 years (6 [4.8%] of 126). Unilateral or bilateral hearing loss occurred in 14 (12.5%) of 112 children with meningitis.

CONCLUSIONS. The morbidity and the mortality of meningococcal infections are substantial. With the recent licensure of meningococcal conjugate vaccines, our baseline trends in meningococcal disease can be compared with those seen after widespread vaccination to assess the success of routine immunization.
Evaluation of the Clinical Assessment Project: A Computer-Based Multimedia Tool to Assess Problem-Solving Ability in Medical Students
Authors: Feldman Mitchell J. , Barnett G. Octo , Link David A. , Coleman Margaret A. , Lowe Janice A. , O'Rourke Edward J.
Published: October 2006

OBJECTIVE. The purpose of this work was to describe Clinical Assessment, a computer-based multimedia patient simulation used to assess the problem-solving abilities of medical students and to evaluate its capacity to guide the assignment of course grade.

METHODS. This was a multisite reviewer-blinded comparison of course grades, National Board of Medical Examiners pediatric examination score, and Clinical Assessment scores at 3 pediatric clerkship sites of the Harvard Medical School. Participants included 470 students completing their pediatric clerkships. Each student's performance on ≤4 Clinical Assessment patient case simulations was compared with National Board of Medical Examiners pediatric examination scores and course grades assigned by clerkship directors based on overall ward performance.

RESULTS. Data from both the National Board of Medical Examiners pediatric “shelf” examination and the course grade were available for 411 students who completed ≥1 Clinical Assessment case. There was a strong correlation between Clinical Assessment score and course grade when comparing students receiving honors versus satisfactory category course grades. Students who ordered more expensive or greater numbers of laboratory tests did not achieve greater diagnostic accuracy on Clinical Assessment. Clinical Assessment had a high positive predictive value for course grade: 95% of students scoring ≥90% on Clinical Assessment achieved an honors category course grade.

CONCLUSIONS. Because nearly all of the students who scored very well on Clinical Assessment received honors category course grades, future high scorers on this examination merit consideration for assigning a high course grade. A computer-based multimedia patient simulation assessment tool provides objective information that can complement a student's National Board of Medical Examiners score and course grade and may assist in evaluating clinical problem-solving ability.
Forty Years in Partnership: The American Academy of Pediatrics and the Indian Health Service
Authors: Brenneman George , Rhoades Everett , Chilton Lance
Published: October 2006

Fifty years ago, American Indian and Alaska Native children faced an overwhelming burden of disease, especially infectious diseases such as pneumonia, meningitis, tuberculosis, hepatitis A and B, and gastrointestinal disease. Death rates of American Indian/Alaska Native infants between 1 month and 1 year were much higher than in the US population as a whole, largely because of these infectious diseases.

The health care of American Indian/Alaska Native patients was transferred to the Department of Health, Education, and Welfare in 1955 and placed under the administration of an agency soon to be known as the Indian Health Service. The few early pediatricians in the Indian Health Service recognized the severity of the challenges facing American Indian/Alaska Native children and asked for help. The American Academy of Pediatrics responded by creating the Committee on Indian Health in 1965.

In 1986 the Committee on Native American Child Health replaced the Committee on Indian Health. Through the involved activity of these committees, the American Academy of Pediatrics participated in and influenced Indian Health Service policies and services and, combined with improved transportation, sanitation, and access to vaccines and direct services, led to vast improvements in the health of American Indian/Alaska Native children. In 1965, American Indian/Alaska Native postneonatal mortality was more than 3 times that of the general population of the United States. It is still more than twice as high as in other races but has decreased 89% since 1965. Infectious diseases, which caused almost one fourth of all American Indian/Alaska Native child deaths in 1965, now cause <1%.

The Indian Health Service and tribal health programs, authorized by the Indian Self-Determination and Education Assistance Act of 1976 (Pub L. 93-638), continue to seek American Academy of Pediatrics review and assistance through the Committee on Native American Child Health to find and implement interventions for emerging child health problems related to pervasive poverty of many American Indian/Alaska Native communities. Acute infectious diseases that once were responsible for excess morbidity and mortality now are replaced by excess rates resulting from harmful behaviors, substance use, obesity, and injuries (unintentional and intentional). Through strong working partnerships such as that of the American Academy of Pediatrics and the Indian Health Service, progress hopefully will occur to address this “new morbidity.”

In this article we document the history of the Indian Health Service and the American Academy of Pediatrics committees that have worked with it and present certain statistics related to American Indian/Alaska Native child health that show the severity of the health-status disparities challenging American Indian/Alaska Native children and youth.
The Effects of Adult-Type Hypolactasia on Body Height Growth and Dietary Calcium Intake From Childhood Into Young Adulthood: A 21-Year Follow-up Study—The Cardiovascular Risk in Young Finns Study
Authors: Lehtimäki Terho , Hemminki Jukka , Rontu Riikka , Mikkilä Vera , Räsänen Leena , Laaksonen Marika , Hutri-Kähönen Nina , Kähönen Mika , Viikari Jorma , Raitakari Olli
Published: October 2006

OBJECTIVE. The effect of adult-type hypolactasia, caused by the lactase-phlorizin hydrolase C/C-13910 genotype, on growth is unknown. We studied whether this polymorphism was associated with body height growth, the use of milk products, or dietary calcium intake.

METHODS. A prospective cohort study was performed among 3596 randomly selected Finnish children and adolescents (3–18 years of age) in 1980, with reexamination in 1983, 1986, and 2001 (after a 21-year follow-up period). Lactase-phlorizin hydrolase C/T-13910 polymorphism was determined for 2265 participants in 2002. Nutrient intakes were measured for 1137, 858, and 1031 subjects in 1980, 1986, and 2001, respectively.

RESULTS. The lactase-phlorizin hydrolase C/T-13910 polymorphism was not related to mean height growth speed for either boys or girls or to final mean body height in adulthood. The consumption of milk products, protein, and calcium was lowest for female subjects with the lactase-phlorizin hydrolase C/C-13910 genotype over the study years, but there were no genotype-related differences in the intake of vitamin D. For boys, significant differences were found in the consumption of milk products but not in the mean dietary intake of calcium, protein, or vitamin D.

CONCLUSIONS. The lactase-phlorizin hydrolase C/C-13910 genotype was not associated with mean growth speed or final mean body height for either boys or girls. However, it contributed significantly to milk product consumption and dietary calcium intake from childhood into young adulthood.
Recruitment Bias in a Population-Based Study of Children With Cerebral Palsy
Authors: Parkes Jackie , Kerr Claire , McDowell Brona C. , Cosgrove Aidan P.
Published: October 2006

OBJECTIVE. The purpose of this analysis was to assess recruitment bias in a population-based study of locomotor ability in children with cerebral palsy.

METHOD. A population-based case register was used as a sampling frame and was considered a highly ascertained record of children with the condition. A twin track approach to recruitment for the Locomotor Study was adopted through: (1) a specialist orthopedic service and (2) a community pediatric network on behalf of the case register. The subjects included children with cerebral palsy aged 4 to 16 years in 2003, able to walk ≥10 m, and a resident in Northern Ireland, as well as their parents.

RESULTS. The Orthopaedic Service identified clinically distinct children with cerebral palsy in terms of type, severity, age, and geographic residence. More families responded to an invitation, and more were ultimately recruited into the study via the Orthopaedic Service compared with a case register using community pediatric contacts. Overall, 37.8% of the eligible cerebral palsy population participated in the Locomotor Study, but there was no evidence of any systematic biases in demographic or key clinical characteristics when compared with nonparticipants. One follow-up reminder led to an increase in recruitment of 10%.

CONCLUSIONS. Care must be taken in the recruitment of children with cerebral palsy through clinic-based populations, although these routes may prove more successful in follow-up. Provided they are comprehensive, case registers have a valuable contribution to make to clinical research by providing a sampling frame including information on baseline characteristics of an affected population.