bluuebunny/crossref_metadata_2025_split huggingface dataset:
Growth Hormone Treatment of Girls With Turner Syndrome: The National Cooperative Growth Study Experience
Authors: Plotnick Leslie , Attie Kenneth M. , Blethen Sandra L. , Sy Judy P. 
Published: December 2021

Objective. To evaluate growth rate and adult height with recombinant growth hormone (GH) treatment in girls with Turner syndrome (TS) and predictors of their growth response.
Methods. Data on girls with TS who were treated with GH in the National Cooperative Growth Study (NCGS) were evaluated. As of January 1997, there were 2798 girls with TS in the NCGS database, 2652 of whom had not previously received GH. Follow-up data on growth were available for 2475 subjects, and data on adult height were available for 622.
Results. The average age of girls with TS at enrollment in the NCGS was 10.1 ± 3.6 years. These patients had severely short stature compared with that of unaffected American girls (height, 118.5 ± 16.5 cm; height standard deviation score [SDS], −3.1 ± 0.9), but their heights were typical of those of American girls with TS (TS-specific height SDS, 0.01 ± 0.9). Treatment with GH for an average duration of 3.2 ± 2.0 years resulted in an increase in height SDS of 0.8 ± 0.7 compared with unaffected girls and of 1.2 ± 0.8 compared with TS standards. Growth rates increased from 4.0 ± 2.3 cm/year before treatment to 7.5 ± 2.0 cm/year after 1 year of treatment. Duration of treatment with GH was the strongest predictor of change in height SDS. After 6 to 7 years of treatment with GH, there was a cumulative change of 2.0 in mean height SDS.
The 622 girls who reached adult height were older when they began taking GH. Their mean height gain over pre-GH projected height was 6.4 ± 4.9 cm after 3.7 ± 1.9 years of treatment. Their adult height was 148.3 ± 5.6 cm.
Conclusions. Although the response to treatment with GH varied, it was associated with highly significant gains in growth and adult height in girls with TS. Duration of treatment with GH was the most important variable predicting adult height.
Optimizing Estrogen Replacement Treatment in Turner Syndrome
Authors: Rosenfield Robert L. , Perovic Nancy , Devine Nancy , Mauras Nelly , Moshang Tom , Root Allen W. , Sy Judy P. 
Published: December 2021

Estrogen has a biphasic effect on growth, stimulatory at low doses but inhibitory at higher doses. Therefore, designing optimal sex hormone replacement treatment in girls with Turner syndrome (TS) who are being treated with growth hormone (GH) involves considering the dose and form of the estrogen as well as the route and timing of its administration. We report here a preliminary analysis of a study to test the concept that an optimal estrogen replacement regimen should consist of estradiol administered in a low dose by a systemic route.The study population consisted of 9 girls with TS who had been treated with GH for 6 or more months. When the girls were 12 to 15 years old, we added depot estradiol at a monthly intramuscular dose of 0.2 mg and increased the dose at 6-month intervals to 0.4, 0.6, and, in 7 of the girls, 0.8 mg. We compared the results in these subjects with those in a matched group of 37 patients with TS in whom routine estrogen treatment had been started at similar ages and who were treated with a similar course of GH therapy.The gain in height at 2 years was 2.6 cm greater in those who were treated with depot estradiol than in those who were treated with routine estrogen. The bone age in the patients who were treated with depot estradiol increased in proportion to their chronologic age, suggesting that this difference indicates an increase in their predicted adult height. We conclude that using very low doses of systemic estradiol to induce puberty before the age of 15 years in girls with TS who are treated with GH, instead of using routine estrogen therapy, can result in increased final heights.
Lack of Correlation Between Growth Hormone Provocative Test Results and Subsequent Growth Rates During Growth Hormone Therapy
Authors: Bell Jennifer J. , Dana Ken 
Published: December 2021

Objectives. To determine whether there is a relationship between the peak GH level in pituitary stimulation tests and the growth rate in response to treatment with recombinant human growth hormone (GH).Methods. We identified 24 843 patients in the National Cooperative Growth Study database who had not been treated previously with GH therapy and divided them into three groups according to the peak GH level in pituitary stimulation testing: 1) &lt;10 μg/L (n = 14 132); 2) ≥10 μg/L (n = 7476); and 3) no test results reported (n = 3235). Growth rates in each group in response to GH therapy were examined.Results. The children in each of the groups responded to GH therapy with a vigorous increase in growth rates (means, 8.4 to 9.5 cm/y) in the first year, followed by a gradual decline and then stabilization at 1.0 to 1.9 cm/y greater than the pretreatment values. There were large overlaps in the growth rates among the groups, but the differences were significant.The growth rates in a smaller group of children (n = 187) who had normal GH responses and normal growth rates before GH therapy increased similarly in the first year of therapy (to 7.7 to 9.2 cm/y), but then declined rapidly to the pretreatment values or lower.Conclusion. Because the GH response to pituitary stimulation testing is inadequate for diagnosing GH deficiency, such testing also is inadequate for determining whether GH treatment should be prescribed in a child with short stature. In addition, the waning response to GH therapy in normally growing short children suggests that this treatment may not have a sustained benefit in these children.
Immunization Performance Measurement in a Changing Immunization Environment
Authors: Rodewald Lance , Maes Edmond , Stevenson John , Lyons Bridget , Stokley Shannon , Szilagyi Peter 
Published: December 2021

Objective.The measurement of performance in the delivery of recommended vaccinations for children is used frequently as a marker for quality of care and as an outcome for studies of interventions to improve immunization coverage levels. The critical element of immunization performance measurement is the determination of immunization status. This methodologic review 1) discusses immunization status as a measure of quality of primary care for children, 2) describes immunization status measures used in immunization intervention studies, and 3) examines selected technical issues of immunization status measurement.Methods and Topics.1) Description of the characteristics of immunization status measurements obtained by a systematic review of studies published between 1980 and 1997 on interventions to raise immunization coverage, and 2) illustration of technical considerations for immunization status measurement using one local database and one national database of immunization histories. Technical issues for immunization status measurement include 1) the need to use documented immunization histories rather than parental recall to determine immunization status, 2) the need to link records across providers to obtain complete records, 3) the sensitivity of immunization status to missing immunization data, and 4) the potential of measures incorporating combinations of immunizations to underestimate the degree of vaccination in a population.Conclusions.Immunization performance measurement has many characteristics of a robust quality of care measure, including high acceptance by primary care providers of routine vaccination, association of immunization status with the conduct of other clinical preventive services, agreed-on technical and programmatic standards of care, and legislative requirements for medical record documentation. However, it is not without challenges. Careful attention to technical issues has potential to improve immunization delivery health services research.
The Social Ecology of Addiction: Race, Risk, and Resilience
Authors: Wallace John M. 
Published: December 2021

Objective.
The purposes of this article are to inform pediatricians and other health professionals of key contextual risk factors that elevate black and Hispanic Americans' likelihood to use substances and to discuss selected protective mechanisms that may shield members of these populations against substance use.

Method.
The article selectively reviews the literature on the epidemiology, etiology, and consequences of alcohol and other drug use among white, black, and Hispanic adults and youth.

Results.
The extant research suggests that historical and contemporary racialized practices and ideologies influence racial/ethnic differences in substance use outcomes, both directly and indirectly, through their influence on the communities in which people of different racial/ethnic groups are placed, through their influence on the structure and process of people's interpersonal relationships, and through the impact that they have on individuals' psychology and behavior.

Conclusions.
Although the emphasis of pediatricians' and many other helping professionals' work focuses on individuals and individual-level behaviors, these behaviors can only be properly examined, diagnosed, and treated when they are understood in light of the community and societal contexts in which they occur.
Using Employer Purchasing Power to Improve the Quality of Perinatal Care
Authors: Castles Anne G. , Milstein Arnold , Damberg Cheryl L. 
Published: December 2021

Large employers have become increasingly involved in helping to set the agenda for quality measurement and improvement. Moreover, they are beginning to hold health care organizations accountable for their performance through marketplace incentives, including the public reporting of comparative quality data and the linkage of reimbursement to performance on quality measures. The Pacific Business Group on Health (PBGH) is an employer coalition that has been prominent in establishing models for collaborative quality measurement and improvement in the California marketplace.
PBGH's involvement in quality stems from an environment in which purchasers were faced with high health care costs, yet virtually no information with which to assess the value their employees received from that care. Research indicating widespread variation in performance across health care organizations and seemingly limited oversight for quality of care within the industry has further motivated purchasers' efforts to better understand the quality of care being delivered to their em-ployees.
Using the purchasing power of employers representing 2.5-million covered lives, PBGH endeavors to encourage the transition of the health care marketplace from one that competes solely on price to one that competes on price and quality. This entails collaborating with the health care industry to develop and publicly report valid performance data for use by both large employers and consumers of health care services. It also includes communicating to the marketplace purchasers' commitment to making purchasing decisions based on quality as well as cost. PBGH efforts to measure, report, and improve quality have been demonstrated by several undertakings in the perinatal care arena, including research to assess cesarean section rates and newborn readmission rates across California hospitals. employer coalition, purchaser, quality measurement, quality improvement, report cards, perinatal quality of care.
Structure and Performance of Different DRG Classification Systems for Neonatal Medicine
Authors: Muldoon John H. 
Published: December 2021

There are a number of Diagnosis-Related Group (DRG) classification systems that have evolved over the past 2 decades, each with their own strengths and weaknesses. DRG systems are used for case-mix trending, utilization management and quality improvement, comparative reporting, prospective payment, and price negotiations. For any of these applications it is essential to know the accuracy with which the DRG system classifies patients, specifically for predicting resource use and also mortality.
The objective of this study was to assess the adequacy of the three most commonly used DRG systems for neonatal patients—Medicare DRGs, All Patient Diagnosis-Related Groups (AP-DRGs), and All Patient Refined Diagnosis-Related Groups (APR-DRGs). A 2-part methodology is used to assess adequacy. The first part is a descriptive analysis that examines the structural characteristics of each system. This provides a framework for understanding the inherent strengths and weaknesses of each system and for interpreting their statistical performance. The second part examines the statistical performance of each system on a large nationally representative hospital database.
The analysis identifies major differences in the structure and statistical performance of the three DRG systems for neonates. The Medicare DRGs are structurally the least developed and yield the poorest overall statistical performance (cost R2 = 0.292; mortality R2 = 0.083). The APR-DRGs are structurally the most developed and yield the best statistical performance (cost R2 = 0.627; mortality R2 = 0.416). The AP-DRGs are intermediate to Medicare DRGs and APR-DRGs, although closer to APR-DRGs (cost R2 = 0.507; mortality R2 = 0.304).
An analysis of payment impacts and systematic effects identifies there are major systematic biases with the Medicare DRGs. At the patient level, there is substantial underpayment for surgical neonates, transferred-in neonates, neonates discharged to home health services, and neonates who die. In contrast, there is substantial overpayment for normal newborns. At the facility level, there is substantial underpayment for freestanding acute children's hospitals and major teaching general hospitals. There is overpayment for other urban general hospitals but this pattern varies by hospital size. There is very substantial overpayment for other rural hospitals. The AP-DRGs remove the majority of the systematic effects but significant biases remain. The APR-DRGs remove most of the systematic effects but some biases remain.
Reducing Cesarean Birth Rates With Data-driven Quality Improvement Activities
Authors: Main Elliott K. 
Published: December 2021

Reduction of cesarean section rates has been a difficult process that has not been easily accomplished by the institution of guidelines. It is more a process of changing physician behavior rather than of medical education. This article analyzed the role of intensive feedback of outcomes to bring about such changes. Two large private obstetric services in San Francisco, CA, were studied. Intensive outcomes feedback using a computerized information system, The Perinatal Data Center, regarding cesarean birth rates and a variety of obstetric outcomes was provided to the medical and nursing staff at one hospital. The other center served as a control. After the first observation period, the outcomes system was introduced to the second hospital. Finally, “open label” feedback, intradepartmental release of everyone's key statistics with names attached, was performed. Active management of labor was not practiced at either hospital.
Results. Cesarean birth rates were stable in the baseline period from 1980 through 1988 at 24% to 25%. Introduction of the Perinatal Data Center outcomes system was associated with a reduction to 21% at the first hospital with no change in the control hospital. Subsequent introduction of the system 3 years later in the control hospital resulted in a decline from 25% to 20.5%. After merger of the two obstetric units and the institution of “open label” feedback, an additional decline to 18.5% was observed.
Conclusion. Physician practice patterns and cesarean birth rates can be altered with the intensive use of comparative outcome data and strong physician leadership. Nonblinded, intradepartmental distribution of outcomes is an even more effective tool.
The Academic General Pediatrician: Is the Species Still Endangered?
Authors: Haggerty Robert J. , Sutherland Sydney A. 
Published: December 2021

Objective.To determine the careers of graduates of the General Pediatrics Academic Development Program (GPADP) and the pediatricians from the Clinical Scholars (CS) Program 8 to 16 years after completion of their fellowship to assess the current state of the academic general pediatrician and to determine the current activities of divisions of General Pediatrics in US medical schools.Design.Analysis of questionnaire data from former fellows of the two programs, who trained during the years 1978 to 1988, as well as of data from questionnaires to all divisions of General Pediatrics (or their equivalent) in all medical schools in the United States.Population.Surveys were conducted of the 111 graduates of the GPADP and the 39 pediatricians from the CS program and all 127 US medical schools.Results.Of the 111 GPADP graduates, 101 were located, and 85 completed the questionnaire. Of 39 CS graduates, 36 were located, of whom 27 completed the questionnaire. Similarities were found between the two groups in percent being in academic positions (74%, GPADP vs 70.4%, CS), percent having achieved tenure (17.8%, GPADP vs 14.3%, CS), and percent of time spent in research (17%, GPADP vs 25%, CS). Considerable differences, however, were found in percent of time spent in direct patient care (35.7% time for GPADP and only 17.8% time for CS) and in direct teaching (25.1% time for GPADP and only 17.6% time for CS). The mean number of articles published was greater among CS professionals (21.4 vs 14 for GPADP, but not statistically significant), as was the mean number of research grants (6.75 by CS vs 4.02 by GPADP). The GPADP fellows had obtained more education grants and more service grants. Both groups were concerned about the lack of time and support for research. Few General Pediatrics divisions had ongoing academic fellowship programs.The current number of new fellows by divisions of General Pediatrics who are educated to do research is small. Only 30 related programs exist in all the medical schools in the United States. However, large divisions of General Pediatrics, responsible for large teaching and clinical service programs, are now in place in the majority of medical schools. This represents progress since 1978, when few generalists were in full-time academia.Conclusion.More than two thirds of both the GPADP graduates and CS professionals are now in academic departments. They have had modest success in obtaining grants, publishing articles, and achieving tenure, but large teaching and service demands and lack of research funds have made it difficult for both groups to be as productive in research as originally hoped. The field of Academic General Pediatrics now is established. It is the responsibility of graduates of these and similar programs to produce creative research and expand fellowship programs, as well as to do good clinical care, if a vigorous field of Academic General Pediatrics is to be achieved.
On Pins and Needles? Pediatric Pain Patients' Experience With Acupuncture
Authors: Kemper Kathi J. , Sarah Rebecca , MPH LicAc, , Silver-Highfield Ellen , Xiarhos LicAc§; Elizabeth , Barnes Linda , Berde Charles 
Published: December 2021

Introduction.Despite its increasing use as a complementary therapy to treat pain, acupuncture is rarely considered by pediatricians, in part due to perceptions that it will not be acceptable to pediatric patients. We wished to describe pediatric pain patients' experience with acupuncture treatment for chronic pain.Design.Retrospective case series.Methods.Subjects were pediatric pain patients referred by the Pain Treatment Service at Children's Hospital in Boston, who went to a pediatric acupuncturist. A research assistant not involved in the patient's care conducted the survey by telephone. Data were analyzed qualitatively and descriptively.Results.Of 50 eligible patients, 47 families were reached by telephone; all agreed to be interviewed. Patients had a median age of 16 years at the time of referral, 79% were female, and 96% were white. The most common three diagnoses were migraine headache (n = 7), endometriosis (n = 6), and reflex sympathetic dystrophy (n = 5). Patients had a median of 8 treatments (range: 0–60) within 3 months (range: 0–48 months); 85% of families paid out-of-pocket. Acupuncture therapies included needle insertion (98%), heat/moxa (85%), magnets (26%), and cupping (26%). Most patients and parents rated the therapy as pleasant (67% children/60% parents), and most (70% children/59% parents) felt the treatment had helped their symptoms; only 1 said that treatment made symptoms worse.Conclusion.Pediatric patients with chronic, severe pain found acupuncture treatment pleasant and helpful. Additional, prospective studies are needed to quantify the costs and effectiveness of acupuncture treatment for pediatric pain.
Reliabilities of Short Substance Abuse Screening Tests Among Adolescent Medical Patients
Authors: Knight John R. , Goodman Elizabeth , Pulerwitz Todd , DuRant Robert H. 
Published: December 2021

Objective.To determine the internal consistency and 1-week test-retest reliability of the Simple Screening Instrument for Alcohol and Other Drug Abuse (SSI-AOD), the CAGE-AA (CAGE questions adapted for adolescents), and 4 modified items from the Drug and Alcohol Problem QuickScreen (DAP-4) among adolescents.Methods.Fifteen- to 18-year-old medical patients (n = 173) completed screening tests during a routine medical visit and then again 1 week later. Internal consistency for each test and retest was calculated using Cronbach's α, and 1-week test-retest reliability was calculated by using Winer's unbiased estimate of the intraclass correlation coefficient (r).Results.The SSI-AOD has good internal consistency (α = .83) and the CAGE-AA questions acceptable internal consistency (α = .60). Alpha varied with gender and race, and item analysis indicated the CAGE-AA test could be improved. As expected, the DAP-4 had a lower α score (.46). All screening instruments studied had high 1-week test-retest reliabilities (ranger = .82–.90).Conclusions.The SSI-AOD is a reliable substance abuse screening instrument among adolescent medical patients. The CAGE-AA questions must be further revised and tested before their use can be recommended. The DAP-4 questions are likely measuring different, but important, constructs.