bluuebunny/crossref_metadata_2025_split huggingface dataset:
Treatment of Mixed Tumors of the Kidney in Childhood, by Robert E. Gross, MD, and Edward B. D. Neuhauser, MD,Pediatrics, 1950;6:843–852
Authors: Randolph Judson 
Published: December 2021

This fundamental paper by a surgeon, Dr Gross, and a radiologist and radiotherapist, Dr Neuhauser, cleaned up the existing information and conflicting results of therapy for Wilms' tumor through 1947. There is a careful review of literature, comments about existing suggestions of preoperative radiation versus postoperative radiation versus radiation only and versus surgery without radiation. The authors then carefully analyze the experience at Boston Children's Hospital over the period from 1914 to 1947. This material is carefully broken down into three periods, 1914 to 1930, 1931 to 1939, and 1940 to 1947. During period I, 1914 to 1930, 27 cases of Wilms' tumor were seen and four cures were obtained for a survival rate of 14.9%. Beginning in 1931, under the able leadership of Dr William E. Ladd, a vigorous approach to the surgery for children with Wilms' tumor was undertaken. The program consisted of a wide transabdominal incision rather than the more classic approach to kidney surgery by a flank incision. This surgical exposure allowed prompt identification and control of the renal vessels and removal, in most cases, of the entire tumor and kidney mass without rupture of the encapsulated tumor. Additionally, Dr. Ladd insisted on careful fluid and blood replacement before and during surgery and a meticulous approach to the anesthestic management of the child undergoing surgery. In previous experience at Boston Children's and other reported centers, there had been a large number of intraoperative deaths. After 1932, there were no deaths from the surgery at Children's Hospital in Boston. In the 1931 to 1939 experience, 31 patients were operated on and ten cures were achieved for a survival rate of 32.2%.
Beginning in 1940, Dr Gross and Dr Neuhauser instituted a program of immediate surgery and postoperative radiation to the bed of the tumor. Thirty-eight children were so treated with a survival rate of 47.3%. This group of patients was subsequently followed for 2½ years so that cures, recurrences, and deaths could be accurately reported. This patient material also emphasized that babies in the first 12 months of life had a far better outlook than did older subjects. The authors also emphasized that if recurrences were to occur, they were usually evident within 9 months after operative removal and radiation therapy. Postoperative radiation therapy was given in daily doses of 200r alternately using three portals, anteriorly, laterally, and posteriorly over the tumor bed reaching a total of 4000 to 5000r using a 200KV machine.
Responses of Children Immunized with Capsular Polysaccharide of Hemophilus influenzae Type b, by David H. Smith, MD, et al,Pediatrics, 1973;52:637–644; andHaemophilus influenzae Type b Capsular Polysaccharide Vaccine in Children: A Double-blind Field Study of 100 000 Vaccinees 3 Months to 5 Years of Age in Finland, by Heikki Peltola, MD et al,Pediatrics, 1977;60:730–737
Authors: Peter Georges 
Published: December 2021

One hundred forty-one children of 5 to 59 months of age were immunized with a single intramuscular dose of 0.67, 3.3, 17, or 67 μg polyribophosphate (PRP), the capsular antigen ofHemophilus influenzae, type b. The immunizations were well tolerated, particularly at doses of .67 to 17 μg. Antibody activity was measured by radioactive antigen binding, using3H-labelled PRP. Doses of 3.3 and 17 μg produced significant antibody rises in nearly 90% of recipients; 0.67 and 67 μg in approximately half. The geometric mean titers were similar at three and six weeks after immunization and were greater with the middle doses.The net antibody increase in responding children was strongly age dependent, but was not related to the preimmunization antibody concentration. Rises in serum bactericidal activity against H. influenzae type b generally accompanied rises in antibody concentration as measured by the antigen-binding assay.A recently developed Haemophilus influenzae type b capsular polysaccharide vaccine was given to 48 977 children 3 months to 5 years of age; an equal number of children receiving group A meningococcal vaccine served as controls. The protection as well as serum antibody response was strongly age dependent. Among children who had received the H. influenzae type b vaccine when 18 months of age or older, there were no cases of bacteremic disease caused by H. influenzaetype b in the first year after vaccination. At the same time 11 such cases were seen in the control group of the same age, a highly significant difference. In the second year after vaccination two cases occurred in the H. influenzae type b-vaccinated group, five in the meningococcal-group A vaccinated group. No protection was seen among children who had been younger than 18 months when vaccinated, even if they received a booster dose of the vaccine.The serum antibody response to the H. influenzae type b polysaccharide, measured by radioimmunoassay, was poor in children below 18 months of age and good in those above it. No effect of the vaccine could be seen on the nasopharyngeal carriage of H. influenzae type b, which was approximately 6% in this age group. Adverse effects of the vaccine were mild.
The Effect of Price Information on Test-ordering Behavior and Patient Outcomes in a Pediatric Emergency Department
Authors: Hampers Louis C. , Cha Susie , Gutglass David J. , Krug Steven E. , Binns Helen J. 
Published: December 2021

Objective.We sought to determine whether information on hospital charges (prices) would affect test-ordering and quality of patient care in a pediatric emergency department (ED).Design.Prospective, nonblind, controlled trial of price information.Setting.Urban, university-affiliated pediatric ED.Methods.We prospectively assessed patients 2 months to 10 years of age with a presenting temperature ≥38.5°C or complaint of vomiting, diarrhea, or decreased oral intake. The assessments were done during three periods: September 1997 through December 1997 (control), January 1998 through March 1998 (intervention), and April 1998 (washout). In the control and washout periods, physicians noted tests ordered on a list attached to each chart. In the intervention period, physicians noted tests ordered on a similar list that included standard hospital charges for each test. Records of each visit were reviewed to determine clinical and demographic information as well as patient disposition. In the control and intervention periods, families of nonadmitted patients were interviewed by telephone 7 days after the visit.Results.When controlled for triage level, vital signs, and admission rates, in a multivariate model, charges for tests in the intervention period were 27% less than charges in the control period. The greatest decrease was seen among low-acuity, nonadmitted patients (43%). In telephone follow-up, patients in the intervention period were slightly more likely to have made an unscheduled follow-up visit to a health care provider (24.4% vs 17.8%), but did not differ on improved condition (86.7% vs 83.4%) or family satisfaction (93.8% vs 93.0%). Adjusted charges in the washout period were 15% lower than in the control period and 15% higher than in the intervention period.Conclusion.Providing price information was associated with a significant reduction in charges for tests ordered on pediatric ED patients with acute illness not requiring admission. This decrease was associated with a slightly higher rate of unscheduled follow-up, but no difference in subjective outcomes or family satisfaction.
Vital Records for Quality Improvement
Authors: Gould Jeffrey B. 
Published: December 2021

The birth certificate and death certificate are important sources of population-based data for assessing the extent of risk and the quality of perinatal outcome. The birth certificate contains the hospital of birth and many items, such as birth weight and race, that can serve as important risk adjusters for neonatal mortality. To assess mortality a second vital record, the death certificate, must be linked to the birth certificate. If the analysis is to be stratified by level of neonatal care or other hospital characteristics, a third file providing these details must also be utilized. The exact vital record formats, recording protocols, and quality control efforts are determined by and differ across each state. Even with these differences, the quality and completeness of vital records and their linkage are reasonable for population-based analyses. Although the most important vital outcome from a neonatologist's perspective is neonatal mortality, vital records can also be used to assess fetal, perinatal, postneonatal, and infant mortality.
The analytic paradigm that is used in quality analysis performed on data derived from the vital record states that observed outcome is a function of risk, chance, and care. Risk is a characteristic or condition such as low birth weight or low 1-minute Apgar score that elevates the probability of an adverse outcome but is beyond the control of the agent responsible for the outcome. Using risk matrices or regression analysis one determines the expected mortality for a specific institution's case-mix. This expectation is usually based on the statewide analysis of infants with a similar risk profile. A standardized mortality ratio is calculated by dividing observed by expected mortality. A hospital with a high observed mortality (12 deaths per 1000) and an even higher expected mortality based on the risk characteristics of its neonates (24 per 1000) would have a standardized mortality ratio of 0.5. Once the effects of chance have been accounted for by statistical testing this finding could indicate that mortality in this hospital is 50% lower then expected.
Although initially intended for legal and broad-based public health purposes, vital records represent an important source of data to inform perinatal quality improvement activities. The optimal usefulness of information derived from vital records requires that clinicians take an active role in assuring that data entry is complete and accurately reflects risk status, clinical factors, and outcomes. However, even a superb database will be of limited usefulness unless it is linked to an initiative that actively involves clinicians committed to quality improvement.
The Neonatal “Sepsis Work-up”: Personal Reflections on the Development of an Evidence-Based Approach Toward Newborn Infections in a Managed Care Organization
Authors: Escobar Gabriel J. 
Published: December 2021

“Rule out sepsis” may be the most common discharge diagnosis among infants admitted to the neonatal intensive care unit. Although the frequency of sepsis, meningitis, and other confirmed bacterial infections has remained constant (between 1 and 5/1000 live births) for many years, the number of infants evaluated and treated is much higher. Each year in the United States, as many as 600 000 infants experience at least one evaluation for suspected bacterial infection during the birth hospitalization. The number treated is estimated at 130 000 to 400 000 per year. Despite massive overtreatment, delayed diagnosis still occurs.The Kaiser Permanente Medical Care Program (KPMCP) considers developing and implementing an evidence-based approach to “rule out sepsis,” a research and operational priority. To achieve these goals, it is essential to consider two key aspects of the problem. First, it is important to adopt a phenomenologic approach that takes clinicians' personal experience into account. This must include reflection on those aspects of experience often considered “irrational” or “subjective.” Second, incorporation of a phenomenologic approach needs to be tempered with sound epidemiologic methods.If one considers these two aspects—physician experience and sound epidemiology—it is clear that much of the existing literature on “rule out sepsis” is of limited utility. Consequently, the KPMCP has conducted its own studies. These are aimed at characterizing the “sepsis work-up,” developing electronic datasets that would permit clinicians to simulate various strategies, and developing techniques for ongoing electronic monitoring.This article summarizes the approach taken by the KPMCP Division of Research. It describes the results of a pilot study as well as the development and use of a dedicated neonatology outcomes database, the Kaiser Permanente Neonatal Minimum Data Set (NMDS). The NMDS database includes the Score for Neonatal Acute Physiology and permits ongoing monitoring of sepsis “work-ups” as well as confirmed cases of neonatal infection. The article also describes how the experience from the pilot as well as the NMDS was incorporated in the design of a much larger study on “rule out sepsis.” Finally, the article describes some important theoretic issues affecting decision rule development and the use of computer simulations in neonatology. These issues are 1) how one handles possible overanalysis of a dataset; 2) how one handles data points that are unstable (eg, the absolute neutrophil count, which can vary considerably depending on age and sampling conditions); and 3) the limitations of decision rules based on computer simulations.
A Block Rotation in Community Pediatrics
Authors: Shope Timothy R. , Bradley Beverly J. , Taras Howard L. 
Published: December 2021

Objectives.To develop, implement, and evaluate a 1-month block rotation in community pediatrics.Interventions.Faculty from University of California San Diego and Naval Medical Center San Diego developed a combined and integrated curriculum for second-year residents in community pediatrics. Resident activities included structured site visits to schools, day care centers, and community organizations that participate in child health promotion, advocacy, public health, and prevention activities. Resident school consultation and child advocacy projects were established and mentored during the block rotation.Evaluation.Formative evaluation of the program by residents was used to shape the program design. Residents' self-perceived competence in eight areas of community pediatrics was measured with questionnaires administered before and after completion of the rotation. Resident involvement in school consultation and child advocacy projects was assessed in a cross-sectional survey.Results.Twenty-three residents completed the rotation during the 1-year study period. Statistically significant improvements in self-perceived competence were noted in all eight areas of community pediatrics. Among residents who were at least 3 months beyond the rotation completion date, 55% (11/20) reported continued involvement with their school consultation or child advocacy project, and 25% (5/20) reported this involvement to be on a quarterly to monthly basis.Conclusions.Two institutions successfully implemented and integrated a block rotation in community pediatrics. Positive short-term improvements were noted in resident self-perceived competence in community pediatrics.
Black and White Middle Class Children Who Have Private Health Insurance in the United States
Authors: Weitzman Michael , Byrd Robert S. , Auinger Peggy 
Published: December 2021

Objective.To compare the health, behavior and school problems, and use of medical, mental health, and special education services of privately insured, middle class black and white children in the United States.Design/Methods.Analyses of the Child Health Supplement to the 1988 National Health Interview Survey, with a nationally representative sample of 17 110 children age 0–17 years.Results.Privately insured middle class black children had fewer chronic health conditions, but were less likely to be reported to be in excellent health (46.2% vs 57.3%) and more likely to have had asthma (8.5% vs 5.8%) or to have been of low birth weight (10.7% vs 5.6%). There were no differences in rates of having a usual source of routine care (92.2% vs 93.8%) or of being up to date with well-child care (79.3% vs 78.2%), but black children made fewer physician visits, were less likely to use physicians' offices, were more likely to lack continuity of care, and were twice as likely to use emergency departments. These differences in use of medical services persisted in multivariate analyses and analyses restricted to more affluent children. Despite similar rates of behavior problems, black children were more likely to repeat a grade (20.0% vs 12.3%) and to have been suspended from school (11.3% vs 5.0%). Although significantly fewer black middle class children received mental health or special education services in bivariate analyses, no differences in receipt of these services were noted in multivariate analyses. All differences reported were significant.Conclusions.Among middle class children in the United States, black and white children have similar rates of health and behavior problems, but black children experience substantially increased rates of asthma, low birth weight, and school difficulties. Although not differing in the receipt of mental health or special education services, middle class black children, even in the presence of private health insurance, have markedly different sources and patterns of use of medical services.
Does a Health Maintenance Curriculum for Pediatric Residents Improve Performance?
Authors: Lopreiato Joseph Onofrio , Foulds D. Michael , Littlefield John H. 
Published: December 2021

Objective.To assess the knowledge and skills of residents in health maintenance and to measure the effectiveness of a new curriculum.Design.Longitudinal cohort study of first- and second-year pediatric residents over 2 academic years (AY). Residents in AY 1995–1996 (n = 32) comprised a control group. Residents in AY 1996–1997 (n = 36) served as a study group who completed a structured 12-week program of reading materials, small group discussions, and case scenarios.Methods.A needs assessment identified 7 topic areas in health maintenance: health screening, immunizations, nutrition, development, behavior, injury prevention, and dental health. Control and study residents' cognitive knowledge, chart documentation, and clinical performance were assessed using a 50-item multiple choice examination, medical records audit, and standardized patient evaluations.Results.Mean examination scores, chart documentation, and clinical performance did not differ significantly between first- and second-year control residents. In the study group, mean examination scores of first-year residents were not significantly better than controls. Second-year residents significantly improved their knowledge about health screening, nutrition, and dental health compared with controls but showed no improvement in other areas. Medical record documentation increased significantly among study residents compared with control residents. Clinically, first-year residents significantly improved in the task of health screening (relative risk [RR] 6.33) and markedly improved (36.8% vs 66.7%) their injury prevention counseling compared with controls. Second-year residents showed significant increases in health screening (RR 6.09) and taking a nutritional history (RR 1.44) compared with controls. Assessment of the curriculum by residents showed a high degree of satisfaction with the program.Conclusions.Pediatric residents who had clinical experience and completed the curriculum demonstrated significant improvements in their medical record documentation and selective gains in knowledge and clinical performance of health maintenance compared with residents with clinical experience only. A structured curriculum in health maintenance and a multifaceted assessment system can identify and enhance the skills of pediatric residents.
Evaluating Child Health Plus in Upstate New York: How Much Does Providing Health Insurance to Uninsured Children Increase Health Care Costs?
Authors: Zwanziger Jack , Mukamel Dana B. , Szilagyi Peter G. , Trafton Sarah , Dick Andrew W. , Holl Jane L. , Rodewald Lance E. , Shone Laura Pollard , Jarrell Lynne , Raubertas Richard F. 
Published: December 2021

Background.In response to the increase in the number of American children without health insurance, new federal and state programs have been established to expand health insurance coverage for children. However, the presence of insurance reduces the price of care for families participating in these programs and stimulates the use of medical services, which leads to an increase in health care costs. In this article, we identified the additional expenditures associated with the provision of health insurance to previously uninsured children.Methods.We estimated the expenditures on additional services using data from a study of children living in the Rochester, New York, area who were enrolled in the New York State Child Health Plus (CHPlus) program. CHPlus was designed specifically for low-income children without health insurance who were not eligible for Medicaid. The study sample consisted of 1910 children under the age of 6 who were initially enrolled in CHPlus between November 1, 1991 and August 1, 1993 and who had been enrolled for at least 9 continuous months. We used medical chart reviews to determine the level of primary care utilization, parent interviews for demographic information, as well as specialty care utilization, and we used claims data submitted to CHPlus for the year after enrollment to calculate health care expenditures. Using this information, we estimated a multivariate regression model to compute the average change in expenditures associated with a unit of utilization for a cross-section of service types while controlling for other factors that independently influenced total outpatient expenditures.Results.Expenditures for outpatient services were closely related to primary care utilization—more utilization tended to increase expenditures. Age and the presence of a chronic condition both affected expenditures. Children with chronic conditions and infants tended to have more visits, but these visits were, on average, less expensive. Applying the average change in expenditures to the change in utilization that resulted from the presence of insurance, we estimated that the total increase in expenditures associated with CHPlus was $71.85 per child in the year after enrollment, or a 23% increase in expenditures. The cost increase was almost entirely associated with the provision of primary care. Almost three-quarters of the increase in outpatient expenditures was associated with increased acute and well-child care visits.Conclusions.CHPlus was associated with a modest increase in expenditures, mostly from additional outpatient utilization. Because the additional primary care provided to young children often has substantial long-term benefits, the relatively modest expenditure increases associated with the provision of insurance may be viewed as an investment in the future.
RENAL WATER REQUIREMENT OF INFANTS FED EVAPORATED MILK WITH AND WITHOUT ADDED CARBOHYDRATE
Authors: PRATT EDWARD L. , SNYDERMAN SELMA E. 
Published: December 2021

The renal water requirement of six rapidly growing small infants on a food mixture composed of solely evaporated milk and water has been compared with the renal water requirement in the same infants on isocaloric feedings of evaporated milk, added carbohydrate and water. The higher protein and mineral intake of the unmodified milk mixture resulted in an 85% increase in the renal solute load compared with the load from the modified mixture. Although this increase in renal load, and hence renal water requirement, may be of little significance under the usual conditions of water intake and expenditure, the margin of safety against dehydration has been decreased. At the same time, this larger renal solute load may be an important factor in compromising water balance and well being unless additional water is supplied whenever the usual intake is appreciably decreased, the extrarenal water expenditure is increased or there is impairment of the ability to produce a concentrated urine.
Thus the practical importance while planning infant feedings of considering properties in addition to purely nutritive factors is emphasized.