First Read

Intravenous Acetaminophen: Coming to a Hospital Floor Near You

2012-01-27T00:01:00.000-08:00

In 2011, an intravenous formulation of acetaminophen was approved for use in the United States. The good news is that this product has been used in Europe for some time so there is experience with it. The bad news is that the experience has not all been good, due to the dosing errors that occur since the solution is 10 mg/ml (not 1 mg/ml). This can result in a serious risk of overdose if not understood when ordering the medication. Dart and Rumack (doi: 10.1542/peds.2011-2345), who are experts in understanding acetaminophen and this new intravenous formulation share with us what we need to know about this product and ways to prevent errors from occurring in a special article being early released this week. This drug will be a lot less painful to deal with from an overdose standpoint if you read this interesting report.

Protein Losing Enteropathy

2012-01-26T00:01:00.001-08:00

Our Case Report Associate Editor Dr. Jeff Malatack shares with us his excitement learned from a case report we are early releasing this month from our January issue:

Protein Losing Enteropathy (PLE) can accompany many varied gastrointestinal pathologies. Dr. Zellos et al. (doi: 10.1542/peds.2011-0937) bring to our attention yet another mechanism causing PLE, malrotation and midgut volvulus. Pediatric surgeons and pediatricians associate malrotation and midgut volvulus with a rapidly progressive abdominal catastrophe due to bowel necrosis, perforation, peritonitis and death unless rapid intervention occurs. The authors report a much more indolent course in a toddler with failure to thrive, hypoalbuminemia, hypogammaglobulinemia and generalized edema, whose malrotation was severe enough to obstruct low pressure vessels including lymphatics and mesenteric veins leading to loss of protein rich lymphatic fluid into the bowel and peritoneum but not severe enough to obstruct high pressure mesenteric arteries. Consequently, no bowel necrosis occurred nor did rapid progression of symptoms expected in volvulus. Once recognized and corrective surgery undertaken, the volvulus was reduced causing the patient’s albumin to increase as the PLE resolved. Put this chronic low grade midgut volvulus on the list of causes of PLE.

Hepatitis A Coverage in Teens — Not a Reason to Shout Hep-Hep Hooray!

2012-01-26T00:01:00.000-08:00

Since 2006 hepatitis A vaccine has been universally recommended to be given between 1-2 years of age and recommended for those over age one through 18 based on risk or desire for protection. Despite its increased availability, we wonder just how well we are doing in getting teens vaccinated against this virus. Dorell et al. (doi: 10.1542/peds.2011-2197) address this issue by looking at data from the 2009 National immunization Survey of Teens to determine coverage in adolescents ages 13 through 17, given that the vaccine has been available since the late 1990s. The results show that less than half of our teens are protected against this virus, and reminds us to offer it to teens who wish to be against the complications of this infection in adulthood. While reading an article on vaccination rates may not excite you, hopefully by including it in my blog I am taking my best shot at reminding you of the import of discussing the benefits of this vaccine with all your adolescent patients.

Recharging the Well

2012-01-25T00:01:00.001-08:00

Dr. William V. Raszka, our Associate Editor, offers the following insight into a current topic in the news:

How long can one pump water from an aquifer before it runs dry? The question seems a bit like a high school math problem, but the answers are not known and the implications are enormous. Aquifers are wet underground layers of rock or sediments from which water can be extracted by a well. For years, scientists have not had a good way to measure how fast aquifers are recharged by surface water. Commonly used dating tools, such as carbon 14, have been useful in archeology but not so much in understanding the flow of underground water.

Now scientists have reported a breakthrough in dating technology using krypton 81. As reported in The New York Times (Science: November 21, 2011), krypton 81 is an isotope present in air. Once trapped underground in water that no longer has contact with air, krypton 81 begins to decay by a factor of two every 230,000 years. Capturing krypton 81 is extremely challenging as there is only one molecule of krypton 81 for every quintillion (1018) water molecules. Using sophisticated technology, scientists were able to capture and measure krypton 81 in water samples obtained from deep in the Nubian Aquifer.

The results suggest that the Nubian Aquifer has been collecting water for millions of years. The bad news is that the aquifer probably only recharges a little each year; thus, under normal circumstances the water level may only rise a few millimeters a year. While the aquifer still contains a massive amount of water, it is shared by four countries: Egypt, Libya, Chad, and Sudan. Rapid or heavy pumping could lead to both local and international conflicts. Already, some lakes and oases supplied by the aquifer are now dry. While water management is often a political rather than scientific issue, better understanding of the hydrology may make it easier to develop and adhere to water management plans.

Noted by WVR, MD

*This filler excerpt can be found in the January 2012 Pediatrics print journal p.152, or via online here.

Traumatic Brain Injury: What Do We Know About Cognitive and Behavioral Function Years Later?

2012-01-25T00:01:00.000-08:00

When a young patient of ours experiences a traumatic brain injury (TBI) for whatever reason, one of the first questions we often get from parents as care becomes stabilized is what will be the patient’s level of development going forward as a result of that injury? Fortunately, two studies are being shared this week that attempt to answer that question. One by Anderson et al. (doi: 10.1542/peds.2011-0311) looks at 40 children who experienced a TBI between the ages of four and seven and follows them and a control group for up to 10 years post-insult. The other study by Crowe et al. (doi: 10.1542/peds.2011-0438) follows 53 children injured under the age of three for an average of 40 months and again compares them to a control group. Both studies reveal similar findings in regard to differences in outcome between less severe and more severe injuries, but also raise the importance of environmental factors contributing to adaptive recovery. How does the environment interact with the anatomic damage that has ensued from the TBI? To make sense of the findings of both of these studies we have invited Dr. Harvey Levin, Professor and Director of Research in the Department of Physical Medicine and Rehabilitation at Baylor, to share his thoughts in an accompanying commentary (doi: 10.1542/peds.2011-3403). These three articles shed new light on the consequences of cerebral injury and I hope you will download these three articles so you can share the results with parents of children who experience a TBI.

Sunscreen Does Not Burn Brightly in the Minds or Skin of Early Adolescents

2012-01-24T00:01:00.000-08:00

During early childhood and continuing into elementary school, parents are quite good at ensuring their children have adequate sun protection and use sunscreen as needed. But what happens when early adolescence arrives with its growing independence? Is sun protection viewed as a priority in the early teens? Dusza et al. (doi: 10.1542/peds.2011-0104) find out this is not the case as they prospectively surveyed more than 350 fifth graders in the early fall of 2004 and surveyed them again three years later to see whether they were sunburned during the preceding summer and if sunscreen was used. The sunscreen statistics that are reported are not shining ones by any means but lend a ray of hope that we might do a better job reminding teens of the importance of taking ownership of their own skin care — and that means use of sunscreen whenever needed during outdoor sun exposure. Even if those of us in the northern hemisphere are experiencing winter right now, reading about our role in promoting sun protection is sure to warm you up.

Urinary Proteome Analysis and Vesicoureteral Reflux: If You Don’t Know How They Relate, Have We Got the Article for You!

2012-01-23T00:01:00.000-08:00

Given the recently published UTI guidelines in our journal, VCUGs, while no longer automatic, still have their place when indicated as per the recommended guidelines. Even if recommended, many VCUGs may still be normal studies and the search continues for a less invasive but sensitive and specific way to determine if high grade reflux is present in a young patient. That is where proteomic analysis comes into play. What are urinary proteomes? They are patterns or expressions of urinary protein excretion that vary depending on the disease or stressor affecting the kidney.

To see if severe reflux has identifiable proteome profile Drube et al. (doi: 10.1542/peds.2010-3467) performed a case-control study of a specific urinary proteome pattern. The pattern differences reveal that the grade IV or V reflux pattern has a high level of sensitivity and specificity and may be the pilot information needed to move ahead with prospective validation in a much larger sample. We opted to publish this study despite its small sample size because the results are statistically significant and may pave the way for future studies to use proteomics to identify disease pathology without the need for more invasive diagnostic studies.

To learn more about proteomics as used to help diagnose reflux, go with the flow and give this article your attention.

Macroglossia: A Large Retrospective Analysis That Is Not Just Tongue-in-Cheek

2012-01-20T00:01:00.000-08:00

We normally associate macroglossia with Beckwith-Wiedemann Syndrome (BWS) but what if it’s not? Prada et al. (doi: 10.1542/peds.2011-1732) share the results of their series of 135 children with macroglossia at Cinncinnati Children’s Hospital Medical Center from 1997 to 2010. More than 13 different diagnoses are represented in this case series, and less than half of those studied (who were referred largely for their large tongues), had BWS. If you want to broaden your differential so that more than BWS rolls off your tongue when you see a patient with macroglossia, don’t miss this interesting article.

The Gum That Binds Us

2012-01-19T00:01:00.001-08:00

Dr. William V. Raszka, our Associate Editor, offers the following insight into a current topic in the news:

What plant is as essential to good ice cream and creamy condiments as it is to the oil industry? Stumped? The answer is guar. According to an article in The Wall Street Journal (Commodities: November 25, 2011), guar is an annual legume principally grown in India and Pakistan. While the bean can be used in animal feeds, guar is the source of a ubiquitous food emulsifier or stabilizer. The guar beans have a large endosperm that contains galactomannan gum. It is this gum that is so valuable to food producers, textile manufacturers, and the textile and cosmetic industries. Guar gum has several interesting properties. It forms a gel in water. Tiny amounts increase water viscosity and in cooking, guar gum is almost eight times more potent than cornstarch in thickening water.

Guar gum impedes ice crystal growth. In the food industry, the largest commercial consumer, guar gum is used to thicken dairy products and help prevent crystals from forming in ice cream. It is used in condiments such as salad dressing to give the fluid a uniform appearance. In baked goods, guar gum is added to dough not only to make it more pliable but increase its shelf life. The gum also prevents water from seeping out of the dough. Guar gum is commonly found in toothpaste, cosmetics, and even pharmaceutical products as a binder. Now, demand for guar has dramatically jumped. As reported in the article, the oil industry also takes advantage of the unique properties of guar gum. Guar gum is added to water, thickening it, and suspending particles of sand and beads. Huge quantities of the resultant slurry are used in hydraulic fracturing to release oil and gas from shale formations.

While only tiny amounts of guar gum are necessary in a half gallon of ice cream, each shale well uses a huge amount of guar, roughly the amount generated from hundreds of acres cultivated vines. The demand for guar has caused prices to skyrocket, so much so that many food processors have had to turn to alternative agents. Fortunately, guar is renewable and amazingly, can tolerate very arid environments. Little is produced in the U.S., only about 2% of the world’s supply, probably because there is no commodities market for it here and the crop is not insured by the U.S. government. Still, given the appetite for this legume, one would expect that more vines will be planted.

Noted by WVR, MD

*This filler excerpt can be found in the January 2012 Pediatrics print journal p.140, or via online here.

Late Intravenous Immunoglobulin in Kawaski Disease Patients: Is It Worth Doing?

2012-01-19T00:01:00.000-08:00

Nowadays we tend to keep Kawasaki Disease (KD) high up in the differential of a child who presents with rash and fever. If we don’t think about it until a week or two after the symptoms have initially presented, can treatment with intravenous immunoglobulin (IVIG) still make a difference in reducing inflammation and preventing coronary artery lesions? Muta et al. (doi: 10.1542/peds.2011-1704) share with us the results of a survey in Japan that compared pair-matched controls of the same age and sex treated with IVIG 4 to 8 days versus 11 to 20 days after presentation of symptoms and signs. While there is some benefit to IVIG in terms of resolving ongoing inflammation, late treatment is not the panacea for prevention of coronary artery lesions. If you don’t think about KD early on in its onset, you might not be thinking rash-ionally in your differential diagnosis when characteristic symptoms and signs present — especially if you want to reduce the risk of coronary arterial aneurysms. Read this article to learn more about the benefits but also the risks of delayed IVIG treatment.

Water-Less Jeans

2012-01-18T00:01:00.000-08:00

Dr. William V. Raszka, our Associate Editor, offers the following insight into a current topic in the news:

One of my boys came home the other day with a new pair of jeans. I was not so much interested in the cut or even the wash but a tag dangling from a belt loop with “Water-less” written in large type. Did the tag mean water less or waterless? According to an article in The New York Times (Science: November 1, 2011), some international jean makers are trying to reduce the amount of water used to make and maintain a pair of jeans. By one estimate, approximately 919 gallons of water are used during the life span of each pair of jeans. This includes the water necessary to irrigate the crops, sew the jeans together, and wash the jeans at home.

Several manufactures underwrite international nonprofit programs, such as the Better Cotton Initiative, that teaches farmers in the developing world sophisticated irrigation and rainwater-capture techniques. Others have introduced stone-washed jeans smoothed with rocks without the addition of water. Customers are urged to wash jeans infrequently, if at all. The interest by denim manufacturers in water conservation highlights a growing problem around the world: water scarcity. Beverage companies have responded by experimenting with bottle cleaning systems that use hot air rather than water. Still, the denim industry is particularly sensitive. Approximately two pounds of cotton goes into the manufacturing of a pair of jeans. With much of the cotton produced on small farms without water holding systems, the water hungry plants are susceptible to drought conditions. According to the article, cotton, the world’s biggest nonfood crop, already accounts for more than 3 percent of the world’s agricultural water use.

So far, the efforts seem to be working. Farmers in India following advice from the Better Cotton Initiative to install drip irrigation systems report up to a 70% reduction in water use, fewer weeds, less pesticide use, lusher crops, and an increase in profits. One denim manufacturer now buys approximately 5% of its cotton from farmers using such techniques and plans to increase that number to 20%. I am happy that our kids are interested in “Water-less” labeled jeans. The next task will be to convince them that jeans don’t need to be washed after each wearing.

Noted by WVR, MD

*This filler excerpt can be found in the January 2012 Pediatrics print journal p.131, or via online here.

Newborn Screening Samples: What Happens to Them After You Get the Results?

2012-01-17T00:01:00.000-08:00

Newborn bloodspot screening plays a critical role in the identification of a myriad of genetic disorders, allowing us to intervene with appropriate management so complications do not ensue. Yet, what happens in state labs once the results have been reported? Those bloodspots may be saved and in turn used for quality assurance testing in a lab, biomedical research and even forensic applications. Did you know that? Should parents consent to the use of the screen for such additional purposes? Botkin et al. (doi: 10.1542/peds.2011-0970) address this latter question in a fascinating study whereby he and his colleagues surveyed more than 3,800 public respondents regarding policies and practices relevant to the retention and use of newborn screening materials. The concept of an “opt-in” consent process is raised and what the public thinks of using such a process will make you consider whether you should do something similar with parents of your newborn patients.

Complementing this study is an additional one by Bombard et al. (doi: 10.1542/peds.2011-2572) who also surveyed the public in eight focus groups in Canada regarding storage of samples and parental choice to use them for further research. The investigators found that the public identified benefits as well as risks of simply allowing this to occur without parental consent. Both studies call for more public education on the risks and benefits of secondary uses of newborn bloodspots. While these articles were in press, we learned of the recent State Supreme Court decision in Minnesota to prohibit the use of newborn screening for other purposes than that of screening the baby - unless informed consent has been provided for other uses of the screen Bearder versus Minnesota from the Newborn Screening Coalition website (Leight and Chrysler: November 22, 2011). This is the first time such statewide decision making appears to have occurred based on the thought that genetic information is inseparable from one’s DNA, and thus a screen belongs only to the owner of that sample.

When we find an issue like this one that has not gotten the public attention it might deserve, we also invite comment. Therrell and Hannon (doi: 10.1542/peds.2011-3416) share with us their thoughts on these two studies as well as this issue in an accompanying commentary. What’s your opinion on a parent’s need to know about and in turn consent to storage and future use of the newborn bloodspot for research? Feel free to share your thoughts in our e-letter column or on our Facebook page once you have read all three interesting articles.

Identifying Food Insecurity

2012-01-16T00:01:00.001-08:00

Our Quality Reports Editor Dr. Alex Kemper offers the following preview of what’s being published in the newest section of our journal:

Dr. Burkhardt et al. (doi: 10.1542/peds.2011-1153) present a quality improvement project to identify food insecurity with screening by pediatric residents. I was really struck by the magnitude of food insecurity and the ability of screening to identify these families. I look forward to the next step — learning about the effectiveness of interventions. However, even without knowing about the outcomes of identification, I think this is really important work. I have heard some say that this is "opening Pandora's box" because food insecurity is so hard to address. On the contrary, I think this is a critical issue for pediatricians and one that we should be doing a better job of in our clinics. What a great training experience for the residents at Cincinnati Children's!

Vegetable Wars

2012-01-16T00:01:00.000-08:00

Dr. William V. Raszka, our Associate Editor, offers the following insight into a current topic in the news:

One of my sons is a professional pizza maker. I asked him what constitutes a vegetable pizza. He looked at me quizzically and replied a vegetable pizza is defined as one that has vegetable toppings. I guess members of Congress did not consult my son when they refused to provide funding to support the Agriculture Department’s new guidelines for the $11 billion federally subsidized school lunch program.

Based on 2009 recommendations by the Institute of Medicine, the Agriculture Department sought to limit the amount of starchy vegetables and sodium in school lunches and increase the number of servings of fruits, vegetables, and whole grains. The goal was to provide nutritious lunches and help fight the childhood obesity epidemic. Some school districts balked, however, and complained that the cost associated with the changes, about 14 cents for each school lunch, were inappropriate in these tough financial times.

As reported in The New York Times (U.S.: November 15, 2011), a number of companies, trade organizations, and lobbying groups vehemently protested the proposed rules. Responding to complaints, Congress voted to block the proposed potato limits. Language requiring less sodium and more whole grains was removed from the spending bill. And, the amount of tomato paste on a slice of pizza must still count as a vegetable serving. The Agriculture Department had sought to change the current guidelines and define tomato paste as a vegetable only if the serving was one-fourth cup or more. This would be in keeping with how other vegetables and fruits are accounted for in the school lunch program.

Because of the requirement to serve a minimum number of vegetables each week, the decision means that pizza is still counted as a vegetable, children who eat a pizza every day for lunch are eating their vegetables, and school districts serving pizza and French fries are in compliance. It also shows just how difficult addressing the obesity epidemic will be. If French fries and pizza are the staple of countless subsidized school lunches, the future looks less than appetizing.

Noted by WVR, MD

*This filler excerpt can be found in the January 2012 Pediatrics print journal p.86, or via online here.

Presidential Pardon

2012-01-13T00:01:00.000-08:00

Dr. William V. Raszka, our Associate Editor, offers the following insight into a current topic in the news:

I did not buy a live turkey this year for Thanksgiving, so when I purchased my bird from the store, it did not so much resemble a bird but a large round package wrapped in plastic. The anonymity of the package may be one reason why I did not feel any remorse planning my holiday meal. However, I wonder what would have happened if I had gone to a farm and selected one to be slaughtered from a gaggle of live turkeys. Would I have felt differently? Would I have bought the turkey and then released it? After all, the President of the United States pardons a turkey each Thanksgiving.

As reported on CNN.com (Holidays: November 22, 2011), the tradition of a Presidential turkey pardon dates back to when Abraham Lincoln was in office. Minutes before the scheduled demise of a pet turkey raised by his son Tad for the holiday meal, Tad burst into a cabinet meeting and pleaded with his father not to kill the bird. President Lincoln wrote the order for a reprieve on a card and the turkey was granted its freedom. The tradition of annual Presidential turkey pardons, however, is a much more recent phenomenon.

President Eisenhower was presented a turkey each Thanksgiving holiday by the National Turkey Federation. President Eisenhower, parsimonious in all his pardons, simply ate the birds. President George H.W. Bush began the modern tradition of pardons in 1989. When presented with a live gobbler for the holiday meal he decreed that the turkey would not be eaten by anyone and granted an official presidential pardon. This year two birds will be selected for pardon. After a Rose garden ceremony, the birds will be taken to Mount Vernon Estates and Gardens where they will be on display until January.

A protected environment for the pardoned turkeys seems like a good idea. I am pretty sure that pardoned domesticated turkeys released into the wild in our neck of the woods would not survive too long. As for me, having raised and then eaten the sheep I raised, I think that “I like Ike.”

Noted by WVR, MD

*This filler excerpt can be found in the January 2012 Pediatrics print journal p.69, or via online here.

Hoarding

2012-01-12T00:01:00.000-08:00

Dr. William V. Raszka, our Associate Editor, offers the following insight into a current topic in the news:

Last week I went to the grocery store to purchase milk, cereal, and fruit. I was heading for the check-out counter when an end-of-aisle display caught my attention. Cans of diced tomatoes, which I use frequently when cooking, were on sale. The sign indicating the price also noted that customers could only purchase three. I wasn’t planning on cooking with diced tomatoes soon and I already had quite a stash in the pantry, but this was a good deal. Anyone facing a similar predicament should know that the placement of food items, cost, and even the exact wording of the signage in most large grocery stores have been carefully choreographed by food manufacturers.

According to an article in Time (The Culture: November 7, 2011), manufacturers have all kinds of tricks to make sure shoppers buy their products and more specifically, buy something that they had not planned on buying. Research has shown that shoppers respond to seemingly small cues. For example, using parquet rather than linoleum floors in a particular aisle conveys a sense of quality and may make shoppers slow. Creating ridges in the floor makes the shopping cart clatter and cause shoppers to instinctively slow. The goal is to make sure the shopper spends as much time as possible looking at the food items. Grocery stores appeal to very primitive human instincts: survival and getting a good deal. While fewer people in the U.S. face food insecurity than most other places in the world, there is a natural tendency to want to make sure there is always enough food. If we can couple that desire with getting a good deal, then dopamine is presumably released and the shopper feels a rush of satisfaction or pleasure.

One approach is to place a limit on the number of individual items that can be purchased. The natural tendency for many shoppers is to hoard the maximum amount as if suspicious that there are not any more cans of diced tomatoes in back. Removing the dollar sign from the price helps disconnect the shopper from the economic cost of putting the food item into the cart. So while I pushed the tiniest cart available around the store, carried a specific shopping list, and avoided the stand-up displays, I was no match for the diced tomatoes. Three cans went into the cart. Who knows, maybe there will be a terrible Vermont snowstorm and I will be happy that I have a dozen cans in the basement.

Noted by WVR, MD

*This filler excerpt can be found in the January 2012 Pediatrics print journal p.54, or via online here.

The Diet Factor in Attention-Deficit/Hyperactivity Disorder

2012-01-10T00:01:00.001-08:00

We are all familiar with the urban legends describing well-behaved children turning into whirling monsters by merely drinking a soda or eating candy. Is there any truth to the impact of diet on attention in children? In this month’s State of the Art Review, Millichap and Yee (doi: 10.1542/peds.2011-2199) do a wonderful job of carefully dissecting the existing data and coming to well thought out conclusions on this challenging topic.

Smiley Faces

2012-01-10T00:01:00.000-08:00

Dr. William V. Raszka, our Associate Editor, offers the following insight into a current topic in the news:

I could hardly believe my eyes. There, at the end of a short text from my wife, was an emoticon. This was surprising for many reasons. First, my wife is not a natural when it comes to texting. She uses an older phone in which each button represents three letters. So for her, texting takes a long time as she deliberately taps each key and waits for the correct letter to appear on the screen. Secondly, we have known each other a very long time and can usually ascertain each other’s mood or intent easily through written or spoken words. So why the :) ? Did she think I would not understand?

As reported in The New York Times (Fashion: October 21, 2011), emoticons, which have been a mainstay of emails and texts between teens, can now be found in conversations between adults and even among professionals in the business community. Some use them to make sure the receiver understands the intent and to avoid any miscommunication. This may be particularly important in an age where much communication is devoid of tone. Others use them to provoke a smile particularly if not a demonstrative person. While teens may use emoticons all the time, in the professional world they tend to be reserved for use in congenial relationships. As the use of emoticons has exploded so has the number of symbols. There are symbols for happiness and sadness of course, but also action (e.g. a hug), or an activity (e.g. music).

This can lead to some problems. While a little yellow smiley face (or frown) can be helpful in conveying a particular emotion, not all symbols transfer across platforms well. For example, a face or hug on one platform may appear as a series of punctuation marks in another, some of which may be confusing. Others find the use of emoticons abhorrent. Language should be specific enough to convey emotions and the need for pictorial representation is yet another example of the degradation of writing skills. While I never use emoticons in my professional correspondence, I happily returned my wife’s text simply with a :) .

Noted by WVR, MD

*This filler excerpt can be found in the January 2012 Pediatrics print journal p.20, or via online here.

Improving Immunizations

2012-01-09T00:01:00.001-08:00

Our Quality Reports Editor Dr. Alex Kemper offers the following preview of what’s being published in the newest section of our journal:

Immunization delivery is a great target for quality improvement. We know that improving immunization rates leads to better health outcomes. Furthermore, measurement of immunization delivery rates is relatively straight forward. Of course, choosing effective interventions can be challenging. Dr. Fu et al. (doi: 10.1542/peds.2010-3610) present their work in immunization quality improvement work in health centers serving low-income individuals and using multiple interventions. I was particularly struck by the use of the autodialer for reminder and recall. That is something that we may try out in our clinic. A great strength of the project is that it was sustainable for over a year.

Crystal Clear Sound

2012-01-09T00:01:00.000-08:00

Dr. William V. Raszka, our Associate Editor, offers the following insight into a current topic in the news:

Similar to most members of her family, my mother has had poor hearing for years. She has tried a variety of hearing aids but none seem to work particularly well. I still cannot talk to her on the phone easily and she has not been to a music concert or a movie in more than 20 years. As a pianist, she misses the opportunity to listen to live performances. Now, however, she may finally have a chance to enjoy a concert.

According to an article in The New York Times (Science: October 23, 2011), more concert halls and other venues are installing loop technology to ensure that the hearing impaired can enjoy crystal clear sound. The technology is not new and has been used in Europe for quite some time. A hearing loop consists of a strand of copper linked to a microphone and installed along the edge of a room. Receivers built into hearing aids and cochlear implants pick up electromagnetic signals from the copper strand. Because the copper strand is transmitting the signal from a particular microphone, the hearing aid is only receiving the sounds from the microphone and not also amplifying other noises in the background. The loop can be installed in concert halls, auditoriums, and even ticket booths with the same effect. The loop has dramatically altered the experiences of the hearing impaired and individuals are stunned by the clarity and richness of the sound.

Venues in the U.S. have been slow to adopt the technology because until recently, most hearing aids sold in the U.S. did not always include telecoils, the specialized receivers. Now, however, more than two-thirds of hearing aids and all cochlear implants sold in the U.S. come with telecoils. There is also the cost to installing the loop, which in an auditorium may cost $10 to $25 per seat. Still, with baby boomers aging and many adults suffering from hearing loss secondary to years of listening to loud music, more and more venues are installing the devices. While the technology has yet to arrive in our area, I may have to surprise my mother and take her on a road trip to a venue with an installed loop. It will be a concert she won’t forget.

Noted by WVR, MD

*This filler excerpt can be found in the January 2012 Pediatrics print journal p.12, or via online here.

A Quick Screen For Risky Drinking by a Teen

2012-01-06T00:01:00.000-08:00

We are always looking for quick and effective ways to elicit information about risk-taking behaviors in our teen patients so we can identify a potential problem before it becomes more serious. This month, Chung et al. (doi: 10.1542/peds.2011-1828) share with us the results of a study in which three questions involving alcohol consumption were used as a brief empirically-validated alcohol screen, one of which turns out to be highly sensitive and specific when it comes to identifying moderate to high risk teen drinkers. The fact that one question can be so sensitive and specific is quite sobering and yet must pique your curiosity so that you will want to link to this early release article and learn more about adding this question to your health maintenance history taking — if you haven’t already done so.

Sleep Problems in the First Three Years of Life: A Wake-Up Call to Pay Attention to Their Frequency and Variety

2012-01-05T00:01:00.000-08:00

If you are not getting asked about sleep issues in your patients, it must be your day off given how prevalent sleep issues seem to be nowadays. But is that just our impression regarding their prevalence or are they really as common as we suspect? Byars et al. (doi: 10.1542/peds.2011-0372) surveyed 359 mother/child pairs in a prospective birth cohort study using questionnaires given to mothers by trained interviewers when their children were 6, 12, 24, and 36 months of age. What follows in this article being early released this week is some great data regarding the most common sleep issues by age as parent-reported, including sleep issues that are less commonly noted by parents despite their potential seriousness (e.g. snoring). In addition, patients who have sleep problems in infancy are more likely to have sleep problems (although potentially different ones) as they become toddlers. This article will certainly wake you up to the need to make sleep issues a more prominent component of scheduled health maintenance visits if they aren’t already.

This Week: A Special Focus on Health Policy in Two Key Areas

2012-01-04T00:01:00.000-08:00

We are featuring two special articles this week that take a thought-provoking look at how we can better unite health, education, fiscal, and welfare bodies and better invest in improving the quality and long-term outcomes for children. This is particularly true in underserved areas of the world where the need for an immediate policy may win a battle but lose a war by moving deploying resources from one pot into another, rather than looking at how the pots of resources dictated by various health policies can be united. Shonkoff et al. (doi: 10.1542/peds.2011-0366) share a unique innovative framework for child survival and enhanced development in a special article that we will read not just as pediatricians, but as citizens of the world who care about the next generation and how they can be successful.

In another special article, Modi et al. (doi: 10.1542/peds.2011-1635) focus on how we can do better from a policy standpoint to shape programs and interventions to improve the role of patient self-management in maximizing treatment and clinical outcomes while reducing unnecessary health care costs. Both of these articles represent innovative thoughts and ideas, which are essential if we are going to remedy the health care crisis we face nationally and internationally.

You’ll find both of these articles of import and interest, and we welcome your comments via e-letters or on our Facebook page.

Physical Activity and Child-Care Centers: No Brainer or Weight Gainer?

2012-01-03T00:01:00.000-08:00

How often do we drive by a child-care center and see children outside actively using playground equipment and having a good time? Well, not as often as we used to, based on a study by Copeland et al. (doi: 10.1542/peds.2011-2102). The investigators extracted data from focus groups involving almost 50 child-care providers from more than 30 different centers and learned that fear of injury, combined with financial barriers of purchasing safe playground equipment, and parental pressures to focus on academics are reducing the extent of physical activity in these centers.

Lack of physical activity can certainly add to one’s risk for excess weight gain even when young, and the authors provide some interesting data and discussion as to what their findings suggest. While no one can fault the desire to have safe child-care environment and a learning environment that promotes school-readiness, when do the risks of being too cautious and academic outweigh the benefits of physical activity for young children? This article will make you think and perhaps get you to contact your local child-care centers to see just how much physical activity is being promoted, and whether you need to advocate or help them rebalance the mental and physical activities that lead to overall health and wellbeing in toddlers and preschoolers. Let us know whether your local centers echo the findings in this study via our e-letters or Facebook page.

From Hedera to Snark

2011-12-29T00:01:00.000-08:00

Dr. William V. Raszka, our Associate Editor, offers the following insight into a current topic in the news:

“You use too many commas,” my daughter told me after reading an article I had recently written. I have reasonably thick skin when it comes to editing, but I was a bit perplexed. While I use commas more frequently than my daughter, who mostly eschews them altogether, I use fewer than my wife. I almost never use colons and semicolons, while my daughter’s writing is littered with them. A co-editor and I have practically come to blows (not really; however I must confess that I do have a fondness for parentheses) over her love affair with the dash. The writer can choose from a large number of punctuation marks: the period, comma, hyphen, parenthesis, and the aforementioned colon and semicolon. How does one decide when each is most appropriate?

According to an article in The Wall Street Journal (Life & Culture: October 22, 2011), the rules regarding punctuation change all the time. Punctuation is a relatively recent phenomenon. Early Western texts had no punctuation whatsoever! By the middle ages, more than 30 different marks were used but the application was quite uneven. Early printers played an important role in codifying the use of punctuation.

Parentheses and commas were first used in the early 1500s. Both of these have stood the test of time and remain in common use -- although not always in correct use. Other punctuation marks have mostly faded from the scene: the hedera (a sideways ivy leaf), pilcrow (a C with a slash through it), and the point d'ironie (a backwards question mark) are three examples. The Internet culture, however, is having a profound effect on punctuation. The greater emphasis on less formal writing (and certainly shorter and pithier missives) has de-emphasized the use of several marks including the apostrophe.

Interestingly, because the intent of the writer is sometimes more difficult to decipher, several new punctuation marks have been proposed to convey emotions: examples include disbelief (interrobang), sarcasm (snark-which is really a recycled point d’ironie), and inquisitiveness (question comma). After my daughter’s comments, I re-read my article. I did not make any changes. I like my little commas and the clarity they can give a sentence (although I will from now on avoid use of semicolons).

Noted by WVR, MD

*This filler excerpt can be found in the December 2011 Pediatrics print journal p.1194, or via online here.

500 Words

2011-12-27T00:01:00.000-08:00

Dr. William V. Raszka, our Associate Editor, offers the following insight into a current topic in the news:

“It is 513 words long. I have to cut something,” lamented my third son. He was applying early action to two colleges and was trying to finish his Common Application admissions essay. The deadline for submission was three days away and after a day of work he had shown the essay to my wife and me. “The essay has to be 500 hundred words or less” he told us. He wanted to know if he should cut out descriptions of the field, the turmoil he felt, or something from his plans for the future. Evidently, our son is not alone in his struggles.

As reported in The New York Times (Education: October 28, 2011), this week many high school seniors are fine-tuning their college admission essays to ensure they meet the new word limit guidelines. After four years with no upper limit length, new guidelines state the essay should be 250-500 words long. The restriction was in response to a general feeling that essays had become too long. However, unlike in other parts of the online application where a strict character limit exists, essays longer than 500 words are still uploaded in their entirety.

Moreover, colleges are not told if the essay is longer than 500 words. In theory, a student could still write an essay of any length. While most college admission officers report they will continue to read all essays regardless of length, they do point out that students exceeding the established guidelines are taking a substantial risk. Without a true fixed word limit, however, many argue that not much difference exists between an essay of 520 and 500 words and that forcing students to chop an essay to conform with an arbitrary limit puts too much pressure on them. As for my son, he re-worded his opening lines dropping some descriptions of the field and happily filed a 496-word essay.

Noted by WVR, MD

*This filler excerpt can be found in the December 2011 Pediatrics print journal p.1185, or via online here.

Prenatal Parental Smoking: A Bad Habit Taken in Vein

2011-12-26T00:01:00.000-08:00

We certainly know the various risks of exposing children to second hand smoke, but what about prenatal exposure? Are the effects of the smoke already taking a toll? Geerts et al. (doi: 10.1542/peds.2011-0249) believe so based on a study they performed that is released online this week. The investigators measured carotid artery thickness and arterial wall distensibility in a cohort of children at age five whose parents (both mothers and fathers) had or had not smoked during pregnancy. The results are quite stark and should be shared with any family that is smoking and pregnant at the same time. Given the vascular complications of primary tobacco smoke exposure that we know of in adults, it’s hard to believe that the same pathophysiology starts playing a role in a yet to be born infant and carries forward into their childhood, but it does. Share these results with families to make a dent in exposure of children to environmental tobacco smoke beginning with their time in utero.

Given the need to help parents stop smoking pre-or postnatally, Rosen et al. (doi: 10.1542/peds.2010-3209) share with us, in a timely systematic review, how successful 18 interventional clinical trials have been in getting parents to quit smoking and remain tobacco-free. While the ideas shared in these studies may be useful, there is much more to be done to find the ideal way to intervene and convince parents not to smoke. Nonetheless, this review article will give you plenty of ideas to try on your patients and hopefully make them and you breathe more easily knowing that by stopping smoking, they are making a difference in improving their children’s health as well as their own.

A New Year and a New Addition to Our Perspectives Columns

2011-12-23T00:01:00.000-08:00

As we prepare to welcome 2012, we are delighted to also welcome a new subject to our Perspectives columns — Global Health. This column, which will rotate every four months with our other ongoing Perspectives columns (focused on medical student education, innovations in residency training, and historical moments in pediatrics), will share insights into a number of issues affecting children worldwide. These articles will be overseen by former AAP President Dr. Jay Berkelhamer who also sits on the Standing Committee of the International Pediatric Association. Dr. Berkelhamer is already busy enlisting colleagues all over the world to share their thoughts on international child health. The first in this series by Cabral et al. (doi: 10.1542/peds.2011-2665) sets the table by providing a brief overview of child mortality across the world and steps being taken to address some disturbing mortality data shared in this important article. Gain some perspective on this important aspect of child health and give this column (and the other Perspectives Columns each month) a read.

Home Sweet Medical Home

2011-12-22T00:01:00.000-08:00

We have published a number of articles describing the benefits of the medical home, especially when it comes to coordinating care for children with special health needs. But what about children who don’t have special needs? Is it worth it to create a medical home environment for these otherwise healthy children? According to Long et al. (doi: 10.1542/peds.2011-1739), it definitely is. Using data from the 2003 National Survey of Children’s Health on more than 70,000 children, the authors show a myriad of benefits of high quality cost-effective health outcomes suggesting we strive to create a medical home environment for all children in our practices, which is what the AAP (and the Affordable Care Act) have been preaching. Now we have some nice evidence that will help us walk the walk rather than talk the talk — so give this article your attention and keep creating medical homes for all your patients!

Lyme Versus Aseptic Meningitis: How Can You Tell the Difference?

2011-12-21T00:01:00.000-08:00

The similarities in CSF findings in a patient with lyme meningitis and viral meningitis can make diagnosing the former difficult, especially if the history for lyme is not obtained. Yet, missing this diagnosis can potentially lead to all kinds of complications. Cohn et al. (doi: 10.1542/peds.2011-1215) test a clinical prediction rule called the “Rule of 7’s” to help determine if lyme meningitis could be possible in their interesting study being released online this week. What is the “Rule of 7’s”? It classifies children as being at low-risk for lyme if all of the three criteria are met – less than 7 days of headache, less than 70% of the CSF white cells are mononuclear cells, and no sign of 7th nerve palsy, which can be characteristic of lyme disease. The authors used a multicenter retrospective cohort to test this rule and found it extremely useful in ruling out lyme meningitis. Of course, a prospective evaluation of this rule is the next step, but you won’t be ticked off using the rule now if you are faced with determining if one of your patients has lyme disease.

A Randomized Controlled Trial That Looks at Early Intervention and Behavioral Outcomes

2011-12-20T00:01:00.000-08:00

How often are we trying to determine if early intervention for behavioral issues truly makes a difference? We think it’s the right thing to do, but what’s the evidence that says so — and how good is that evidence? This week, Nordhov et al. (doi: 10.1542/peds.2011-0248) help strengthen the quality of the evidence supporting the need for early intervention programs. They share results of a randomized controlled trial of one early intervention program in terms of behavior at five years of age for a cohort of infants born preterm compared to similar preterms who did not get the intervention and a control group of term babies. What was detected by parents and preschool teachers makes for some interesting results and should make you eager to read the full text of this article. I certainly found it interesting, especially in terms of if parents or teachers noted a difference from the intervention and those who did not.

The Arrest Rate for Youth in the United States: It’s a Crime That is Increasing

2011-12-19T00:01:00.000-08:00

It’s been more than four decades since there was a survey of self-reported arrests in children under the age of 18, as well as in late teens and young adults. Brame et al. (doi: 10.1542/peds.2010-3710) describe the prevalence of arrests (excluding minor traffic violations) from 1997 to 2008 in a disturbing article being released this week online. Using the National Longitudinal Survey of Youth, the authors note a substantive increase in arrests (perhaps as high as 25% of those surveyed), as well as describe the types of crimes that resulted in arrests. Simply sharing the information with adolescents during their health maintenance visits may help focus some prevention efforts. Crime certainly doesn’t pay, but reading this article may pay off in us helping our teen patients stay out of trouble.

Bunny Slopes

2011-12-16T00:01:00.000-08:00

Dr. William V. Raszka, our Associate Editor, offers the following insight into a current topic in the news:

Several ski resorts in Vermont opened this weekend. Around here, this is usually eagerly anticipated and big news. The last of the ski swaps and ski sales are taking place and people are getting ready for the season to begin. This year, as in the past few years, my wife and I will not have to worry too much about getting the kids to the mountain. They all have appropriate and properly fitted equipment. Years ago, however, the story was quite different. We would pack the minivan with spare mittens, helmets, foot and hand warmers, snacks, and just about anything that might make the day more enjoyable.

Still, it was hit or miss. One year, my wife and I didn’t get a single chance to ski together because one of our children developed cold hands and feet the first day of skiing and refused to ski again. One of us had to stay in the lodge with him while the others enjoyed their time on the slopes. According to an article in The Wall Street Journal (Life & Culture: October 12, 2011), ski resorts have realized how important beginner and novice skiers are to the success of a family ski vacation. To ensure that the newest skiers have a successful outing, they have redesigned not only the activities but even the slopes themselves. For example, T-bars and rope tows are being phased out. New skiers can ride to the top of the bunny slope on a conveyer belt or on special lifts that use magnets to literally stick the kids to the seat. New ski jerseys have handles built into them so picking up fallen skiers is much easier.

Bunny slopes are now often immediately adjacent to the lodge and have been groomed so that gravity will take the skiers straight down the hill and not to one side. Many toddler ski programs include play rooms equipped with TV, DVDs and hot chocolate for the frequent breaks. There are several good reasons to provide new skiers with a great experience. Since the population that skis is aging and young riders, those less than 18-years-old, only make up 30% of current skiers, the number of lessons for first time skiers continues to fall. Ski resorts hope that by making skiing pleasant for the young skiers, both parents and children alike will want to return. While this sounds great, I still advise parents to invest in warm mittens and boots for their youngest skiers.

Noted by WVR, MD

*This filler excerpt can be found in the December 2011 Pediatrics print journal p.1180, or via online here.

The Female Voice

2011-12-15T00:01:00.000-08:00

Dr. William V. Raszka, our Associate Editor, offers the following insight into a current topic in the news:

We have a GPS navigation system that we share among our cars. Similar to most other GPS navigation systems, the voice that tells us when to turn is female. I have driven in a lot of cars with navigation systems and every single one has had a female voice. Some systems have given the driver the option of selecting a female voice with a foreign accent (in the U.S., Australian female is quite popular) but I have yet to meet a driver here in the U.S. that has a device with a male voice. And now, the new iPhone sold in the U.S. uses an assistant, Siri, which has a female voice.

According to an article on CNN.com (Tech: October 21, 2011), there are several reasons for the overwhelming predominance of female computer voices. Most people find women’s voices more attractive than men’s. Automobile manufacturers learned this while designing voice prompt systems years ago. Data from focus groups showed that drivers overwhelmingly preferred female over male voices. Furthermore, it is easier to find a female rather than a male voice that most people like. In popular culture, computers that are helpful or subservient tend to be female, e.g. the computer on Star Trek. Computer voices that convey malevolence or authority tend to be male. Two well-known examples are HAL 9000 in “2001: A Space Odyssey” and Auto, in “Wall-E”.

Of course, there are cultural variations. In Germany, BMW had to recall cars with a female voice prompt system because German men refused to take directions from a woman. Conversely, in the UK, where Siri has a male voice, online forums have beseeched Apple to provide Siri with a female voice. As for me, I am quite used to taking directions from a female voice. I remember James Bond in “Thunderball” telling the woman driving him in a car that he does not mind being driven by a woman, just taken for a ride.

Noted by WVR, MD

*This filler excerpt can be found in the December 2011 Pediatrics print journal p.1172, or via online here.

The Black Death

2011-12-14T00:01:00.000-08:00

Dr. William V. Raszka, our Associate Editor, offers the following insight into a current topic in the news:

The Black Plague. The Black Death. These are but two terms for the great pandemic that swept through Europe in the mid-14th century. After arriving in Italy in late 1347, the plague spread rapidly across the continent. Within five years, between one-third and one-half of Western Europe’s populations had succumbed to the disease. For some time, scientists assumed that Yersinia pestis was the etiologic agent of the Black Death.

However, because the signs and symptoms of Y. pestis seem different now than historical records of the Black Plague, some questioned this assumption. As reported in The New York Times (Science: October 12, 2011), any remaining doubts about the relationship between Y. pestis and the Black Death were put to rest last year after the identification of Y. pestis DNA in plague victims from across Europe. Researchers, however, were still perplexed by the virulence of the organism in 14th century Europe.

To better understand how the organism killed so many people and so quickly, researchers isolated and sequenced the entire genome of Y. pestis from the teeth of four plague victims who died in London in 1348. The genome was then compared to that of modern strains. Little difference was detected between the ancient and modern strains. Of the 4.6 million DNA base pairs found in Y. pestis’s single chromosome, only 97 are different between the two. Moreover, only a dozen or so changes occur in genes coding for structural properties. While scientists plan to recreate and study the 1348 organism, so far the genetic analysis suggests that other factors played a large role in the mortality associated with the Black Plague. At the time the plague arrived, malnutrition was endemic. The weather had cooled and become much wetter, crop failures were common, food was scarce and the Hundred Years War had begun in 1337.

All of these factors contributed to a highly susceptible population. While recovering fragments of microbial DNA cannot reveal everything about an organism, the exact order of base pairs plays an important role in determining virulence. This type of investigation opens the door into exploration of other epidemics and a better understanding between host-parasite relationships. Sequencing an ancient microbe is quite an amazing feat.

Noted by WVR, MD

*This filler excerpt can be found in the December 2011 Pediatrics print journal p.1125, or via online here.

Too Much Love

2011-12-13T00:01:00.000-08:00

Dr. William V. Raszka, our Associate Editor, offers the following insight into a current topic in the news:

Like many others, I have admired both the beauty and engineering of the mollusk called the Chambered Nautilus. Nautilus pompilius, the best-known species of nautilus, has figured prominently in popular culture since the Renaissance when the shells became the staple of curiosity cabinets or made into elaborate drinking vessels. In Victorian England, the Chambered Nautilus was both the subject of poems and a popular decorative item. Now, however, this creature, whose fossil record dates back 500 million years, may be loved too much and because of that, faces extinction.

According to an article in The New York Times (Science: October 24, 2011), the Chambered Nautilus is facing extinction because jewelry made from its lovely shell has become increasingly popular. The shell, often substituted for pearls or made into a variety of items, can be purchased relatively inexpensively on numerous web sites and in stores. Unfortunately, for the Chambered Nautilus, it is easy to catch. The creature lives along the steep banks of deep corals in warm waters off the western Pacific Ocean. While the depths preclude diving, baited traps are quite effective in capturing the cephalopod. No regulations govern the catching and sale of the Chambered Nautilus. This has led to over-harvesting. Because it may take the Chambered Nautilus up to 15 years to reach sexual maturity, the rapidly dwindling stocks are of great concern.

A recent expedition to the Philippines documented orders of magnitude fewer specimens. While other creatures facing extinction (e.g., the Polar Bear), have been accorded endangered species status, no such protection has been afforded the Chambered Nautilus. While scientists are trying to learn more about this ancient creature and others lobby for its protection, I will avoid purchasing products made from its shell and advise others to do the same.

Noted by WVR, MD

*This filler excerpt can be found in the December 2011 Pediatrics print journal p.1116, or via online here.

The Good Divorce

2011-12-12T00:01:00.002-08:00

Dr. William V. Raszka, our Associate Editor, offers the following insight into a current topic in the news:

A friend of ours drove our daughter home recently. After talking in the driveway for a few minutes, we invited her into the house for a glass of wine. During our conversation, I noticed that she was no longer wearing her engagement or wedding rings. Also, she had started working again after a long absence from the work force. We learned a few weeks ago that she and her husband, both good friends of ours, may be divorcing. I had seen him several times over the summer, and although never with his wife, he seemed fine and had never said anything about her. Similarly, she seemed fine and never said a word about him.

This prompted me to wonder, is there such a thing as a good divorce? As reported in The New York Times (Fashion: October 28, 2011), it could be that Generation X, those born between 1965 and 1980, approach divorce a bit differently than previous generations. After all, Generation X entered marriage in a different way as 60% chose to live with their future spouse before marriage and almost 80% stay married for more than 10 years. Moreover, all states now uphold joint custody of children, whereas 30 years ago only three states did. Maybe this generation is more clear-eyed both about entering and leaving a marriage. With many divorced couples sharing parental duties, energy has to be directed on the children rather than lobbing bombs at each other.

Another explanation may be that divorce is easier when couples fall out of love. If there is no passion left in the marriage, is there likely to be passion in the divorce? While “good” and “divorce” may not be a natural pairing, for our friends the dyad may apply. As for our friends, we saw them drift apart over the years. Both seem happier and more animated now. They have enough financial power so that while not as well off as previously, they are both doing okay. They share schedules and pick-ups for the kids and both children seem to be adjusting without any major difficulties. Still, I can’t help but wonder, what happened to the passion? I am sad for that loss.

Noted by WVR, MD

*This filler excerpt can be found in the December 2011 Pediatrics print journal p.1108, or via online here.

Long Term ELBW Followup

2011-12-12T00:01:00.001-08:00

Our Case Report Associate Editor Dr. Jeff Malatack shares with us his excitement learned from a case report we are early releasing this month from our upcoming January issue:

John Muraskas et al. (doi:10.1542/peds.2010-0039) provide a long term follow up of two of the smallest surviving newborns in reported literature. The infants were 260 and 280 grams at birth and are being reported at follow up at 5 and 20 years post delivery respectively. It is notable that neither infant had a severe intracranial hemorrhage (IVH). One had a grade I and the other no IVH at all. The infants were both members of multiple birth pregnancies and clearly not only severely premature but also suffered from IUGR. At the current time the 20 year follow up patient is in college and the 5 year follow is making good developmental progress. This report in no way substitutes for large populations of infants that have been stratified based on survival and quality of survival vs. gestational age and/or birth weight, but it does let one know about what is possible in the profoundly low birth weight infant.

Use of Rantidine in Preterm Infants: Not As Benign a Therapy as We May Have Thought

2011-12-12T00:01:00.000-08:00

Have you ever treated a preterm infant with gastroesophageal reflux disease with an H-2 blocker like ranitidine and thought the risks if any were mild? Well, you may want to think again, based on some worrisome results shared by Terrin et al. (doi: 10.1542/peds.2011-0796) in which almost 275 infants born at 24 to 32 weeks (weighing 401 to 1500 grams) were enrolled in a prospective observational study and were stratified for outcomes depending on whether or not they received ranitidine. The outcomes measured included risk of infection, necrotizing enterocolitis, and fatal outcome. In all three situations ranitidine increased the risk significantly of these unpleasant and even fatal outcomes. If you don’t want to experience extra heart-burn in managing preterm infants with reflux, then read this study and think twice before you order the ranitidine in this population of tiny patients.

Recruiting Overseas

2011-12-09T09:31:00.000-08:00

Dr. William V. Raszka, our Associate Editor, offers the following insight into a current topic in the news:

The main topic of conversation along the soccer sidelines these days has nothing to do with the weather, politics, or even the economy. The main topic is the college application process. Stories are swapped about how ill-prepared the students are for selecting a college, the importance (or not) of the ACT scores, where others have looked, and how hard it is to get into one of the “premier” schools.

While there are many talented young men and women at our local high school, only a few of the 400 graduating students will get into an Ivy League or NESCAC (New England Small College Athletic Conference) school. Parents earnestly debate whether applying early action (the consensus is no) or early decision (the consensus is yes) improves the likelihood of being accepted into one of these schools. While we fret about the 10% admission rate to the most competitive schools, imagine the worry among Indian parents.

As reported in The New York Times (World: October 13, 2011), the acceptance rate at The Indian Institutes of Technology is less than 2% among students who score high enough on standardized examinations to even apply. The most competitive schools essentially require perfect scores on the final high school examinations or entrance examination to be considered. Simply put, there are far too many talented youth applying for the few positions available. For many students, the alternative is to apply to U.S. schools. Indian students are now the second largest group of foreign students in the U.S. While many have historically gone to graduate schools, the number of applicants to undergraduate schools is surging, up 20% a year for the past few years. Many schools, including Ivy League schools, now recruit in India and are looking to establish partnerships with Indian schools.

For most Indian students, studying in the U.S. allows for greater flexibility and creativity. The downside is that the cost can be staggering. Tuition at an Ivy League school can be orders of magnitude higher than a comparable Indian University. So, when parents ask me about my son, I merely reply that he’s in the mix for the colleges he wants and that he will have options. I can’t ask for more than that.

Noted by WVR, MD

*This filler excerpt can be found in the December 2011 Pediatrics print journal p.1086, or via online here.

Durability of Improvement and Follow-Up after Newborn Hearing Screening

2011-12-09T00:01:00.000-08:00

Our Quality Reports Editor Dr. Alex Kemper offers the following preview of what’s being published in the newest section of our journal:

The Quality Reports section is nearly one year old. During this time, I have learned of some really innovative and exciting approaches to improving care across the pediatric healthcare enterprise. I often wonder the degree to which important improvements are sustained and what the characteristics are of those improvements that are long lasting. Payne et al. (doi: 10.1542/peds.2011-0566) present a decade of improvement in decreasing nosicomial infections in the NICU setting. Most interestingly, sustained improvement through a bundle of related interventions seems to have a carry over effect to other important areas, such as nutrition, use of central lines, and respiratory management. Success leads to success. I hope that this is a lesson that those in the midst of starting a quality improvement project or arguing for resources to help improve quality can remember.

Assuring follow-up after newborn hearing screening has been a challenge. Although some programs have low recorded rates of follow-up, there has long been debate about whether this simply reflects failure to document appropriate follow-up. Deem et al. (doi: 10.1542/peds.2011-0912 -- early released December 12th!) report the development of quality measures based on current screening recommendations along with specific goals. Use of these measures with feedback to the hospitals helped identify gaps in quality and have led to strategies for improvement. This is an important step and a nice model for other hospitals. I look forward to finding out whether this leads to improvement over the long term. A lot of resources, including a significant amount of funding, has been directed toward improving newborn hearing screening. Hopefully, this common sense approach will work.

Sexting: How Prevalent and How Serious Is the Problem?

2011-12-08T00:01:00.000-08:00

We are certainly well aware of the concerns raised in the lay press regarding youth texting sexual images using electronic devices such as computers and smart phones — a behavior commonly referred to as “sexting”. Yet, how commonly is this being done by youth? Mitchell et al. (doi: 10.1542/peds.2011-1730) attempt to answer this question using a national telephone survey of more than 1,500 Internet users between the ages of 10 and 17. The data could be seen as good news and bad news. The good news is the small percentage of teens that actually participate in sexting, but the bad news is that some teens do this and may experience the legal consequences of such actions.

To gain a better understanding of just how often teens are arrested for sexting, Wolak et al. (doi: 10.1542/peds.2011-2242) sent mail surveys to more than 2,700 law enforcement agencies and followed-up by phone with investigators to better characterize the circumstances that bring sexting events to the attention of the police.

These two articles will allow you to learn more than perhaps you wanted to know about sexting, but reading them will better equip you to discuss this topic with your adolescent patients and help them understand why sexting is not something anyone should engage in. You’ll want to text your colleagues to read these articles so they too can be better equipped to discuss this difficult subject with their patients.

Pediatric Translational Research

2011-12-07T00:01:00.001-08:00

Translational research has become a catch word which we often equate with "bench to bedside" but in reality there is an equal component of bedside to bench since the clinical setting is the nidus for the generation of hypotheses that can be tested at the bench. Use of tissue samples is especially challenging in Pediatrics for many reasons described in this month's State of the Art review where Brisson et al. (doi: 10.1542/peds.2011-0134) address best practices for biobanking and tissue sampling. This review is most appropriate at a time when funding agencies are increasingly interested in integrated approaches.

Feeling the Pressure to Treat Adolescent Hypertension: How Different Specialties Deal with the Problem

2011-12-07T00:01:00.000-08:00

There is a strong emphasis nowadays to try to standardize treatment of common pediatric and adult medical conditions. Guidelines exist for chronic diseases like asthma and diabetes, but when it comes to treating hypertension in adolescents, is there a standard pathway for management? Yoon et al. (doi: 10.1542/peds.2011-0877) provide an answer to that question that may surprise you. Using Medicaid claims data from 2003-2008, approximately 4,300 adolescents with primary hypertension were reviewed for whether or not they received antihypertensive pharmacologic therapy and what that therapy was. Patients were further divided by ethnicity as well as type of physician treating the patient (i.e. adult versus pediatric primary care). The results are anything but standardized and show differences in treatment by specialty as well as by ethnicity of patient. The variety of treatments used raises more questions than answers and makes you wonder about the outcomes of the various treatments prescribed. Hopefully reading this interesting collection of data will elevate your curiosity but not your blood pressure as you review how to treat your hypertensive teens. Better yet — it may motivate you to look at your own outcomes relative to the treatment you are using.

What Do You Do When IVIG By Itself Is Not the Answer for Treatment of Kawasaki Disease?

2011-12-06T00:01:00.000-08:00

While intravenous immunoglobulin (IVIG) has become the standard drug of choice for treatment of Kawasaki disease (KD), about 20% of patients do not seem to respond to this therapy. What’s the backup plan? Ogata et al. (doi: 10.1542/peds.2011-0148) offer a suggestion as a result of doing a randomized trial on patients predicted to have refractory KD based on the use of a scoring system (the Egami score) that used the patient’s age, length of illness, platelet count, C-reactive protein, and alanine aminotransferase level. Once patients were found to have a score predictive of refractory disease they were randomized to either get IVIG or IVIG plus intravenous methylprednisolone (IVMP). Just how well the combination therapy does in this study can be determined by reading the results and the interesting discussion that follows. You may find yourself making a rash-ional decision to try this combination on your own patients if they don’t respond initially to IVIG but don’t take my word for it — read the study and then decide for yourself.

The Ethics of Testing Children for Adult-Onset Genetic Diseases

2011-12-05T00:01:00.000-08:00

In our ongoing quarterly Ethics Rounds, our Ethics Editor, Dr. John Lantos (doi: 10.15420/peds.2010-3743), has provided us with one of the most topical dilemmas we can think of — what to do when parents request testing for their children for diseases that will not manifest themselves until adulthood. If you haven’t read one of our Ethics Rounds articles, where have you been? In a back and forth discussion by two ethicists who are confronted with two interesting cases, you’ll not only gain insight into how to handle this situation when a parent requests such testing, but I suspect you will want to go back and read the other Ethics Rounds columns that have been published since we started this interesting series of articles. It would not be ethical if you didn’t read this article, so make the right decision and link to this interesting feature in our journal to learn more. If you disagree with the decisions reached, you can always share your own opinions with us either via an e-letter or on our journal’s Facebook page. We welcome your comments on this article and any others that we publish.

Sports-Related Concussions: What Is the Mechanism of Injury?

2011-12-01T00:01:00.000-08:00

We have all become appropriately concerned about the possible long-term effects of a sports-related concussion in our patients, and even more concerned when it comes to repeat concussion. Yet, why is this? Is it due to structural neural alterations, metabolite changes in neurons, or reduction in cerebral blood flow? Maugans et al. (doi: 10.1542/peds.2011-2083) investigated these possibilities in 12 children using multiple diagnostic and imaging modalities to sort through the pathophysiologic possibilities. I won’t give away the results in my blog, but suffice it to say there is good brain food for thought in this study that will make us concerned whenever our patients undergo a sports-related concussion. Get in the concussion game by knowing as much as you can about the physiology involved in this injury so parents of our patients will be less eager to have their child speedily returned to play.

Speaking of when to return to play, more and more athletes are being given neurocognitive testing before and after their head injury. Do the results of this testing help to slow down return to play? They absolutely do according to data shared in an article by Meehan et al. (doi: 10.1542/peds.2011-1972). If your local high school teams are not considering preseason and post-concussion neurocognitive testing, this article may convince you to advocate for such testing in your local high school athletic programs.

Doing Less with More

2011-11-30T00:01:00.000-08:00

With the availability of tests and images that can be ordered nowadays, one might think that the safest thing to do is take advantage of these new diagnostic technologies (as well as the not so new ones) to insure a higher quality and safer care to our patients. Yet, when it comes to quality and safety, more may not be better – as discussed in a fascinating commentary by Schroeder et al. (doi: 10.1542/peds.2011-2726) that I suspect will be cited and shared frequently once it is read. A safe bet would be to read it and think how your own practice reflects the message being conveyed. I would love to hear your opinion on this commentary either through our e-letters column or via our Facebook page. The best responses may be published in an upcoming issue of our journal.

My Left Foot

2011-11-29T00:01:00.002-08:00

Dr. William V. Raszka, our Associate Editor, offers the following insight into a current topic in the news:

Last week, I let my 16-year-old daughter drive us home from her late afternoon soccer practice. As she only has her learner’s permit, I was the front seat passenger. She eased out of the parking lot but immediately had to stop at the stop sign. After a few choice words for the driver of the car immediately behind us, she pressed the gas pedal and the car began to lurch forward. My left foot immediately and instinctively pressed the imaginary clutch pedal on the passenger side of the car. After we stalled out, I gently and calmly (but not really) explained to her once again the timing for releasing the clutch and pressing the gas pedals.

While I still drive a manual stick-shift and insist that my kids learn how to drive it, these types of cars are fast disappearing. As reported in The Wall Street Journal (Eyes On The Road: September 7, 2011), fewer than 10 percent of new cars and light trucks sold in the U.S. are equipped with a manual transmission and clutch pedal. While cars with manual transmissions are more fuel efficient than those equipped with automatic transmissions, technologic advances have narrowed the gap in fuel economy.

In Europe, however, where gas prices are considerably higher, automakers have been refining “clutch-less” manual transmissions to exploit the gas savings. A car equipped with a clutch-less manual transmission can be driven in automatic mode, where the car’s computer does all the shifting, or in manual. While in the manual mode, a button is used to manually shift the gears; depressing the + side of the button shifts the car into a higher gear while pressing the – button downshifts. The driver never has to worry about depressing a clutch pedal. For the first time, clutch-less transmissions are being offered in U.S. cars.

While the option is fairly pricey, a car equipped with a clutch-less transmission saves 2 mpg over even a regular manual transmission car. The technology has spread to high end cars noted for their speed and acceleration. In this market, however, the reward is not so much fuel economy but speed. Drivers using clutch-less transmissions can shift faster than drivers using a traditional manual transmission. As for me, I still really enjoy working the stick and the pedal. As for my daughter, she is much smoother in first gear these days and justifiably proud of her driving (and shifting) skills.

Noted by WVR, MD

*This filler excerpt can be found in the November 2011 Pediatrics print journal p.909, or via online here.

Clarithromycin for Prevention of Bronchopulmonary Dyspasia: Consider It in the Setting of Colonization with Ureaplasma Urealyticum

2011-11-29T00:01:00.001-08:00

Every so often we run across a study that makes us reconsider how we treat a fairly common problem — in this week’s case, bronchopulmonary dysplasia (BPD). A study we are early releasing by Ozdemir et al. (doi: 10.1542/peds.2011-1350) reminds us first that being colonized as a premature infant with ureaplasma urealyticum increases the chances of that infant developing bronchopulmonary dysplasia and if that organism is detected, the risk of BPD can be decreased by treating the baby with clarithromycin. How this organism may predispose a baby to BPD and just how significant the results are when these babies are treated (and they are significant) are well worth learning about by reading this early release online article. If anything, it may make you or your local neonatology unit reconsider how often to assay for ureaplasma in our tiniest patients.

Keeping Abreast of Factors Associated with Exclusive Breastfeeding

2011-11-29T00:01:00.000-08:00

While we do all we can to encourage breastfeeding at birth (or should be doing all we can), does that mean a mother will opt to exclusively breastfeed for the first six months? Jones et al. (doi: 10.1542/peds.2011-0841) answer that question using data from the cross-sectional 2007 National Survey of Children’s Health of children ages six months to five years. What may surprise you is that factors responsible for exclusive breastfeeding to six months are not the same as those associated with the initiation of breastfeeding at birth. To learn which factors contribute to both initiation and prolonged exclusive breastfeeding, latch onto this article and learn more.

Improving Medication Reconciliation

2011-11-28T00:01:00.001-08:00

Our Quality Reports Editor Dr. Alex Kemper offers the following preview of what’s being published in the newest section of our journal:

We all know that medication reconciliation is central to patient safety. In my experience, this can be especially challenging for children with special healthcare needs, who often receive care in many different settings. Of course, it is exactly these children that would most benefit from careful medication reconciliation. Rappaport et al. (doi: 10.1542/peds.2011-0993) present findings from a multi-pronged approach to improving the process, which included education, feedback to physicians, use of an electronic medical record, and financial incentives. I think one of the important take-home lessons from this project is the role that workflow plays in completion. The finding that time pressure in the afternoon decreases completion of medication reconciliation is an important and unexpected finding. I wonder if this finding is generalizable. As a “morning person,” I’d hate to think that my care delivery is worse in the afternoon.

Taking Our Best Shots at Some Important Vaccine Articles – Part 2

2011-11-28T00:01:00.000-08:00

Last week we shared two of six articles in the upcoming issue. This week, we release the other four. We begin with an important study by Chaves et al. (doi: 10.1542/peds.2011-0017) describing the disappearance of infant varicella with the implementation of the varicella vaccination program in the United States. Even though infants are not eligible for vaccine, the role of herd immunity or possible better immunity in pregnant mothers is making a difference, with dramatic drops in the incidence of infant varicella. But don’t take my word for it — read the study to learn more.

Recently, we published an article discussing the frequency, which parents are requesting alternative vaccine schedules from their pediatricians (doi: 10.1542/peds.2011-0400), and the results were concerning. What this article did not address was what pediatricians thought of using an “alternative” schedule when parents requested such a schedule. While you might have thought pediatricians would oppose such a schedule, this article shows that is not always the case. To gain a better understanding of what pediatricians think about non-AAP recommended immunization schedules, and which vaccines they are more prone to administer off-schedule, you’ll have to roll up your sleeves and inject yourself into the data shared in this interesting and somewhat concerning study.

One of the reasons vaccines may not be given on time is if parents are working and cannot bring their children in on schedule — or is this an urban, or even rural, myth? Sohn et al. (doi: 10.1542/peds.2011-0931) have attempted to study this by looking at vaccine timeliness in low-income families affected by welfare reform from 1997 to 2004 in working and non-working parents. The interface between working and receiving welfare plays a role in whether or not vaccines are given on time — and the reasons for this are nicely discussed in this article in ways that may prove useful in devising better ways to make sure low-income families get their children vaccinated in a timely manner.

Lest you doze off with all these vaccine articles, Franck et al. (doi: 10.1542/peds.2011-1712) look at sleep duration following vaccination in infants with or without the administration of acetaminophen. The results are fascinating and don’t necessarily show what you might expect. I’ll tell you now that acetaminophen does not significantly influence sleep duration post-vaccines, but the time of day when vaccines are given may be playing a role (or at least has an association) with the duration of sleep post vaccination. You won’t fall asleep reading this one, and my guess is, you’ll want to share the results with families of infants you vaccinate so they know what to expect in terms of post-vaccine sleep.

Finally, to find some common threads in this quilt of multiple vaccine articles, Dr. Ed Marcuse (doi: 10.1542/peds.2011-2922), who is one of our national champions for vaccinating all children with all recommended vaccines, offers some perspective on the myriad of vaccine articles we are publishing this upcoming month in a commentary that, like a regularly scheduled vaccine, should not be missed.

New Thoughts on the Mechanism of Biliary Atresia

2011-11-25T00:01:00.001-08:00

We know how important it is to keep a close eye on jaundiced babies who stay jaundiced a week or more after birth – and to check to make sure the bilirubin is not conjugated -- suggestive of what we have thought was the evolution of possible biliary atresia (given that early detection and treatment has been associated with better long term outcomes in these babies). Yet this week, Harpavat et al. (doi: 10.1542/peds.2011-1869) share some new findings on biliary atresia — i.e. that direct bilirubin levels in those babies with biliary atresia are elevated higher than controls even when the total bilirubin level is below the level that warrants phototherapy. This suggests that this disease is active as early as birth and perhaps allowing us to detect it and treat it with a Kasai procedure even sooner than we currently do. To help make sense of this study, we have invited pediatric gastroenterologist Drs. Neal LeLeiko and Ezequiel Neimark to comment on this article (doi: 10.1542/peds.2011-2774) and shed some light (not just phototherapy) on the findings and whether they suggest we consider screening earlier for conjugated bilirubin abnormalities than we normally do.

Making A Point About Acupuncture Safety in Children

2011-11-25T00:01:00.000-08:00

If you haven’t had patients ask you about the benefits of acupuncture for a variety of symptoms (e.g. headache), it’s only a matter of time, and when that time comes, it is important to have read something about the safety of this modality as well as its effectiveness. This week, our journal targets the safety of pediatric acupuncture through a systematic review by Adams et al. (doi: 10.1542/peds.2011-1091) that identified 37 studies summarized in terms of serious and not so serious adverse events. The bottom line is a relatively safe one (as has been shown for adults), but to get more of the specifics and a better understanding of just what the side effects can be in children who receive acupuncture, take a sharp look at this review and learn more.

Getting to Australia

2011-11-24T00:01:00.000-08:00

Dr. William V. Raszka, our Associate Editor, offers the following insight into a current topic in the news:

One of the enduring mysteries of our species is how and when we populated the continents. The traditional model is that ancestors of modern humans migrated out of Africa in a single wave. Once in Arabia, one group headed north toward Europe to become the ancestors of all Europeans. A separate group headed east to become the ancestors of East Asians. The ancestors of the Australian aborigines split off from this group and settled in Australia.

However, as reported in The Wall Street Journal (World: September 23, 2011), recent genetic evidence suggests otherwise. Researchers compared the genomes of two West Africans, three Han Chinese, and two Europeans with the genes found in a 100 year old lock of hair from an Aborigine man who had lived in a remote part of Australia and therefore unlikely to have any European genes. Their surprising find suggest that Aborigine ancestors were part of an early modern human exodus from Africa but split off from this group approximately 70,000 years ago. The ancestors of modern Europeans and Asians split from each other approximately 30,000 years ago. Once the Aborigine ancestors settled in Australia around 50,000 years ago, no other populations arrived. If this is correct, Aborigines would represent one of the oldest continuous populations outside Africa.

Another conclusion is that the Aborigine ancestors were remarkably resourceful. To reach Australia, not only would they have had to make use of boats but would have had to use the boats without being able to see their destination. Water levels were lower then. Explorers would not have been able to see the Australian landmass before embarking on their journey. While provocative, this study is unlikely to be the final answer to how and when modern humans left Africa. As gene-sequencing technology continues to progress, more studies such as this will help us learn more about who we are and where we came from.

Noted by WVR, MD

*This filler excerpt can be found in the November 2011 Pediatrics print journal p.925, or via online here.

Recent Trends in Internet Violence Suggest Opportunities for More Preventive Measures

2011-11-23T00:01:00.001-08:00

The number of articles in the lay press about cyber-bullying of our children and teenagers has gotten a lot of attention — so how prevalent is this type of behavior on the internet? Ybarra et al. (doi: 10.1542/peds.2011-0118) studied the responses of more than 1,500 pre-teens and teens ages 10-15-years-old over three years through online national surveys to see whether the rates of violent experiences such as bullying and harassment and exposures to hate sites increased over the study time period. While overall rates of violent exposures and experiences did not increase over the three years, the odds of having a violent experience online increased, specifically in those who had an increased rate of online and text messaging, as well as with aging. This article has far more great information for anticipatory guidance in our visits with adolescents. Log on to our online journal or simply link to this article and then consider emailing it to others or at least texting them so they can read and learn from it as well.

Body Mass Changes in Children: When Should We Worry About Increasing BMI Trends?

2011-11-23T00:01:00.000-08:00

While measurement of BMI is (or should be) a key component of a health maintenance visit,we continue to worry about increases in BMI over time. We have wondered whether there is a particular key growth period when a BMI increase may have long-lasting implications for obesity as our patients move into adolescence and young adulthood. Fortunately, Datar et al. (doi: 10.1542/peds.2011-0114) studied changes in BMI, in particular looking at children in this country during elementary and middle-school years to identify critical periods of excess gains in BMI. The investigators studied almost 6,000 children over nine years starting in kindergarten for BMI trends and changes. Interestingly enough, the biggest gains occurred in early elementary school years and not in middle school — even for those with normal BMIs in kindergarten. If this doesn’t make us rev up our obesity prevention efforts during early school years, I am not sure what will. There is a lot more information to be gleaned here — so weigh into this article to learn more.

Fever Without Source in Children 3-36 Months: The Times They Are A-Changin’

2011-11-22T00:01:00.000-08:00

It seems like only a decade or two ago when an infant or toddler presented to an emergency department with a fever without localizing source, they were automatically subjected to a CBC, U/A, blood and urine cultures and often a shot of ceftriaxone before being sent home (if not admitted). Nowadays, however, given the great vaccines that exist to prevent many of the more serious life-threatening infections from occurring, it appears that less is being done to children in this age group than in prior decades — but evidence to support that last claim has been lacking until this week, when a study by Simon et al. (doi: 10.1542/peds.2010-3855) of emergency evaluation of fever without source is released online in our journal. The authors used data from the National Hospital Ambulatory Medical Care Survey from 2006 - 2008 to identify emergency department visits in children 3 to 36 months of age who presented with fever without source. What was and was not done to these children — or should I say for these children — makes for an interesting read. One might expect that at least the majority of children might have their urine examined, but as the data show, that is not necessarily the case. Which factors are associated with diagnostic tests and treatment and which are not, should test your curiosity and result in downloading this important article: a snapshot of what is and is not being done to febrile children in emergency departments around the country.

In Search of Perfect Fruit

2011-11-21T00:01:00.001-08:00

Dr. William V. Raszka, our Associate Editor, offers the following insight into a current topic in the news:

A friend of mine and I play a game in which we exchange photographs of raw food products and ask each other to guess what it is. As she lives in Thailand, I have had to bone up on SE Asian fruits, vegetables, and herbs. Recently, however, I was flummoxed by an unusual cross between an apple and a pear. As reported in The Wall Street Journal (Food & Drink: September 7, 2011), breeders in the U.S. have for years crossed different fruit species in search of the perfect fruit. It is usually a painstaking process.

First, all the flowers of the “mother tree”, the one which will produce the desired fruit, are stripped of petals and pollen producing anthers. Workers then touch each of the remaining pistils with pollen taken from a donor fruit tree. Alternatively, bees are released into an enclosed area that contains the mother tree and a sample of pollen from the donor fruit.

The fruit produced by the mother tree is then harvested and planted. Not until this seedling bears fruit will the breeder have any idea whether the experiment has worked. The goal is to produce a fruit that is sweet, hardy, and easy to grow, survive shipping, and have a long harvest season. If the fruit meets all these criteria, farmers will be able to charge a premium price, up to 50 cents or $1.00 a pound. However, only about 1/1000 of the new fruits make it to market.

Recent interspecies fruits that have made it to the U.S. market include the Pluot and Aprium, both of which are crosses between plums and apricots, and the Peacharine, which is a cross between a peach and a nectarine. Interestingly, despite the fact that these new fruits are the product of genetic modification, they have not generated the same concern or controversy as other genetically modified foods. This may be because everything is done by hand and mimics to a large extent, what could happen in nature.

As for me, I am still disappointed that I lost the challenge. I think I will send her a photo of a Pluerry (a cross between a plum and cherry under development) and see how she does with that.

Noted by WVR, MD

*This filler excerpt can be found in the November 2011 Pediatrics print journal p.839, or via online here.

Taking Our Best Shots at Some Important Vaccine Articles – Part 1

2011-11-21T00:01:00.000-08:00

We have recently been receiving so many good articles dealing with different vaccines and their benefits that rather than scatter them across a few issues of our journal, given their timeliness we opted to place them all together in the print version of the December issue — but we will be early releasing them online this week and next.

Infants are not the only ones to benefit from the use of vaccines. Stokley et al. (doi: 10.1542/peds.2011-1048) turn their attention to adolescents and how well we are doing getting some of the newer vaccines administered to teenagers. While we are doing better, the results suggest we have room to improve. To see if you are one of those who need to do even more to get your adolescents vaccinated and to understand the reasons why teens are not getting vaccinated based on national survey data, you need to give this vaccine article your attention.

In other vaccine news — while parents certainly want vaccine manufacturers to figure out how to combine multiple vaccines into a one combination shot to reduce the pain and discomfort in their children, pediatricians may find themselves being reimbursed less than if they gave each of the component vaccines separately. To determine if this is true or not, Shen et al. (doi: 10.1542/peds.2011-0025) studied the effect on charges and payments to pediatricians over two years in a comparison study of a combination vaccine (Pediarix) versus the single component vaccines given at the same time. The authors offer some suggestions on ways to make the combination vaccine a win-win for both patients and pediatricians — but rather than have me reveal the sharp points made in the Discussion Section of the paper, you need to peruse this article instead.

Digital Impressions

2011-11-18T00:01:00.000-08:00

Dr. William V. Raszka, our Associate Editor, offers the following insight into a current topic in the news:

Two of my children are still in high school. One, a senior, is applying to college, while the other, a junior has already begun her search. We have spent a fair amount of time deciding to whom the ACT or SAT scores should be sent and whether they should attend a showcase soccer or lacrosse camp to impress one of the coaches.

What we have not discussed nearly enough is what has been posted on their Facebook pages. As reported in USA Today (Education: September 22, 2011), college admissions officers frequently search social media for information about applicants. Approximately ¼ of admissions officials at 359 selective colleges reported that they viewed Facebook pages while 20 percent performed a Google search to learn more about applicants.

While the practice is still controversial, some schools forbid admission officers from performing such a search, schools that conduct searches report that students live in a social world and that anything posted can contribute in a positive or negative way to the student’s application. Unfortunately, for 12 percent of applicants, what was posted on social media negatively impacted their chance for admission.

Findings that hurt applicants included vulgar language, photographs of underage drinking, and evidence of plagiarism. Admission officials will also act on tips about inappropriate postings. For example, one school rejected an applicant because she had posted explicit pictures of herself. While it is unclear how many applicants benefitted from what is posted on social media, some college admission officials evaluate the student’s digital literary skills. Students with a strong digital presence can be considered more highly qualified.

As for me, with some trepidation, I performed a brief Google search on my two children. I was much relieved only to see a pretty funny picture of my son with three of his friends on his Facebook page. Still, we will have a conversation about posting to social media and making sure that they know that whatever is posted can be found and viewed by others.

Noted by WVR, MD

*This filler excerpt can be found in the November 2011 Pediatrics print journal p.866, or via online here.

Delayed Acyclovir, Increased Length of Stay, and Mortality in Neonatal Herpes Infections

2011-11-16T00:01:00.000-08:00

Empiric acyclovir in all infants at risk for sepsis in the first month of life has not yet become the standard of care, perhaps for cost-benefit reasons. Yet, two articles being early released may make us rethink whether empiric acyclovir becomes an addition to the usual ampicillin/gentamicin regimen or perhaps earlier consideration of manifestations of this disease so that acyclovir can be administered as soon as possible in a sick newborn, especially one with skin findings. The first article by Shah et al. (doi: 10.1542/peds.2011-0177) is a multicenter retrospective cohort study of over 1,000 neonates less than 28-days-old with HSV infection. Mortality was shown to increase with delayed administration of acyclovir, and the authors call for immediate administration of this drug the moment one considers doing a PCR test for HSV. The second study by Aronson et al. (doi: 10.1542/peds.2011-0948) looks at children with eczema herpeticum and again, delay in the recognition of this disorder and in turn initiation of acyclovir led to increased length of stay for hospitalized children. If ever there were two articles to lower your threshold to consider herpes and rash-ional use of acyclovir in your neonatal and dermatologic differentials, these are the two to consider!

Corn for Dinner

2011-11-15T00:01:00.000-08:00

Dr. William V. Raszka, our Associate Editor, offers the following insight into a current topic in the news:

Last night, we served corn with dinner. We did not buy the corn at the supermarket but directly from the farmer who lives a few miles down the road from us. “You’ll like it,” he had told me. “The corn is super sweet right now.”

As I removed the silk from the ears before roasting them, I thought that the corn really did not look different from any other corn I had cooked this summer. And, after cooking, it really did not taste particularly different either. It was good but not memorable. I wondered, what makes one ear of corn better than another? Is there much variation in the corn we eat? When we grew our own corn, we thought it good but that was chiefly because I could go out to the garden with one of the kids to pick a few ears for dinner. Like thousands of others, however, we had bought our seeds from catalogues supplied by large seed companies.

So while we enjoyed our home grown corn, it really wasn’t very different from a lot of corn produced in the U.S. We could not re-use the kernels for planting the following year as they were patented. Furthermore, as the corn we were eating was a hybrid, the offspring were likely to be quite different from the parent strain.

As reported in The New York Times (Blogs: September 21, 2011), finding a different or unique strain of corn can be quite challenging. While “heirloom” species have become quite fashionable of late, many of these could actually be found in seed catalogues a few decades ago.

Perhaps the most dramatic example of a unique strain is that of the corn grown by the Tuscarora on the Tuscarora Reservation in northern New York. This corn has been part of the tribe for hundreds of years. It has never been sold or marketed. Each year, the best corn is saved for planting the following year. This means that an ear of corn today may not look the same as an ear of corn 50 or 100 years ago. It, is, however, very different looking from much of what one can buy in the store. Is it better? That is hard to answer but it is certainly different, and diversity whether in plants or humans, is worth celebrating.

Noted by WVR, MD

*This filler excerpt can be found in the November 2011 Pediatrics print journal p.847, or via online here.

Cold Water Blues

2011-11-14T00:01:00.000-08:00

Dr. William V. Raszka, our Associate Editor, offers the following insight into a current topic in the news:

One afternoon last week, two of my children played high school soccer games. The fields were muddy and the play physical. By the end of the afternoon, their previously white uniforms were covered in mud and appeared more brown than white. That night my wife and I washed their uniforms. As we put the uniforms into the washer, my wife remarked that they would have to be washed in hot water. I was more than a little surprised. After all, we keep the thermostat at 64F in the winter, have low flow (more like fast drip) shower heads, and my wife recycles everything. Why would she wash the clothes in hot water? Evidently, my wife is not alone in her views.

According to an article in The New York Times (Business: September 16, 2011), using cold water detergents to wash clothes in cold water has not caught on in the U.S. Even in Germany, where there is even a greater interest in reducing energy costs, cold water detergents do not sell well. That more than three-quarters of the energy costs associated with washing a load of clothes goes to heating the water seems lost on the average consumer.

Marketing campaigns touting the energy saving associated with using cold water detergents and washing clothes in cold water have not been effective. One problem is that most people seem to know that hot water really does clean better than cold water.

However, water temperature is not the only determinant of whether clothes are cleaned effectively; the mechanical force applied to the clothes and the detergent used play critical roles. Detergents are now formulated far differently than even a decade ago. Many are specifically designed to work in cold water. Cold water detergents use different surfactants and enzymes than typical detergents. The formulation ensures that they clean as effectively as traditional detergents.

Blinded head-to-head comparisons have shown that cold water detergents can clean clothes very well and as effectively as top-rated detergents. As for us, when I tried, ever so gently, to remind my wife that cold water works well, she seemed unimpressed by my laundry acumen (disclaimer: I wash all my own clothes. I never sort them and only use cold water which is definitely not her style). The uniforms were washed in hot water. I guess I will just turn the thermostat down to 62F this winter.

Noted by WVR, MD

*This filler excerpt can be found in the November 2011 Pediatrics print journal p.954, or via online here.

Treatment of Kimura’s Disease with Intravenous Immunoglobulin

2011-11-11T00:01:00.001-08:00

Our Case Report Associate Editor Dr. Jeff Malatack shares with us his excitement learned from a case report we are early releasing this month from our upcoming December issue:

Dr. Hendron et al. (doi: 10.1542/peds.2011-0867),writing out of Northern Ireland, provide a report of the first pediatric use of intralipid (IL) as an antidote for an accidental tricyclic antidepressant ingestion by a toddler. The intensivists caring for this child first used standard of care therapy as dictated by the local poison control center's protocol but added IL therapy to the management when it was apparent that the patient was progressing despite standard management. The authors were mindful of the reported effectiveness of IL treatment of adults with tricyclic overdose, which prompted their emergent use of this new therapy. The finding of reversal of a bupivicaine overdose by intralipid 20 years ago was serendipitous, but once confirmed in an animal model, the approach has caught the attention of poison management experts. The mechanism is still being sorted out but it seems that IL is effective in those overdoses and ingestions when the drug of interest is lipophilc and lipid soluable. It is likely that the lipid acts as a sink to capture drug and remove it from circulation from where it might bind to tissues and cause harm. Hendron et al. give a nice description of the research supporting this approach. It appears that anesthesiologists and intensivists will add IL to danatrolene and other reversing pharmacologic agents sitting on their easily reachable shelf. IL will likely find utility in use for many fat soluable drugs taken either accidentally or intentionally in overdose.

Dosing Out Some Important Information on Appropriate Antibiotic Prescribing: How Are We Doing and Can We Do Better?

2011-11-11T00:01:00.000-08:00

Despite so much being written about the dangers of overprescribing antibiotics for what may likely be a virus, are we writing fewer prescriptions in this era of antibiotic resistance? Hersh et al. (doi: 10.1542/peds.2011-1337) attempt to answer that question using the National Hospital Ambulatory Medical Care Survey from 2006-2008. Unfortunately, the results are not the most-pleasing and suggest there is still work to be done to limit the use of broad-spectrum antibiotics, especially when the patient simply has non-specific respiratory symptoms. In addition, the authors report on other variables (such as patient age, geographic area of the country, and insurance) that are associated with higher use of broad-spectrum antibiotics.

When you are done reading the article by Hersh et al.— go on to the one that follows by Di Pentima et al. (doi: 10.1542/peds.2010-3589) who share the results of a unique antibiotic stewardship program, thanks to the help of a computerized information system at a children’s hospital (Alfred I. duPont Hospital for Children). The authors look at the frequency of prescribing antibiotics during the three years before and after implementing this computerized surveillance system. The results are dramatic and well worth reading about, so I would prescribe a double-dose of both articles as essential when it comes to being a better steward of proper antimicrobial use.

Arthritis and Exercise

2011-11-10T00:01:00.000-08:00

Dr. William V. Raszka, our Associate Editor, offers the following insight into a current topic in the news:

My father has osteoarthritis and my mother rheumatoid arthritis. I call them frequently and ask what they have been doing. Almost invariably they report that they have not done much at all. Their approach to managing joint pain is to sleep in, rest, and avoid exercise. I am pretty sure that is not the regimen their physicians have recommended. I remind them that physical activity is good for joints. Unfortunately, they don’t really believe that is true. My parents are not the only adults with arthritis who are not exercising.

As reported in the Los Angeles Times (Health: August 31, 2011), in a study of 1,000 adults aged 49-84 with knee osteoarthritis, “only 13 percent of men and 8 percent of women met federal guidelines of 2.5 hours of moderate-intensity, low-impact activity each week.” Something as simple as walking a dog can be beneficial. Part of the problem may be that initially, exercise can be a bit painful.

The longer individuals put off exercising, the more likely it is they will experience some pain at the start of their exercise program. This leads to a vicious negative cycle. Exercise is not only good for joints but contributes to overall fitness and weight loss - both of which are beneficial.

The best way to get adults such as my parents exercising again is not known. One approach might be to encourage them at the onset of their disease so that exercise becomes part of their daily routine. My own approach has been to remind my parents that their dog is obese and going stir-crazy.

While they may not exercise for their own health, they love their dog and want to ensure her continued good health. So, after such a reminder, my mother will often take the dog for a walk. They both seem happier afterwards.

Noted by WVR, MD

*This filler excerpt can be found in the November 2011 Pediatrics print journal p.891, or via online here.

Acetaminophen and Asthma: Not Necessarily a Good Combination

2011-11-09T00:01:00.000-08:00

We are well aware of the increased prevalence of asthma in this country, but less aware of what might be contributing to the increase. This week, pulmonologist John McBride (doi: 10.1542/peds.2011-1106) looks at the association between asthma severity and the use of acetaminophen in a special article being released online. Why the use of this drug increases the prevalence and severity of asthma may rest with acetaminophen causing glutathione depletion in airway mucosa. There is certainly controversy over this hypothesis and even over the existence of this interesting association — and yet Dr. McBride reviews many studies describing this association. Rather than get hot under the collar thinking about the role of acetaminophen in worsening asthma symptoms, take a deep breath and don’t miss reading this special article.

Recent Advances in Management and Treatment of Hereditary Angioedema

2011-11-08T00:01:00.000-08:00

Given the clinical presentation of hereditary angioedema and its rarity, unless family members are known, it may be difficult to differentiate this condition from a severe allergic reaction. The therapies for the latter are not effective for the former. Therefore this could lead to significant delays in providing appropriate treatment. In some cases, the condition is fatal and rapid intervention is needed. Since half of the patients present in the first decade of life, pediatric practitioners need to be aware of this disease and of the development of new therapeutic and prophylactic interventions. This State of the Art Review article by Sardana and Craig (doi: 10.1542/peds.2011-0546) provides these new insights in a clear and evidence-based manner.

Coffee to Prevent Depression

2011-11-07T00:01:00.001-08:00

Dr. William V. Raszka, our Associate Editor, offers the following insight into a current topic in the news:

We have a set routine in our household. Before going to bed, I program the coffee maker so that by 5:30 AM, a huge pot of fully caffeinated coffee has been brewed. Once I get up in the morning, I bring my wife, who is still in bed, a large mug of coffee. In a few minutes or so, I refresh her cup. At about this time she becomes conversant.

Given that she probably has about four to six cups of coffee each morning before going to work, I have always wondered if there were any medical problems associated with her caffeine consumption. She is never jittery and despite the trials and tribulations of managing four older teens in the household, never gets down or depressed (while my moniker is Dr. Doom). Now it turns out that coffee may actually have health benefits.

As reported in The New York Times (Blogs: September 26, 2011), a study involving more than 51,000 nurses between 1996 and 2006 showed that drinking caffeinated coffee protected against the development of depression. Coffee drinkers were 20 percent less likely to develop depression and that the more coffee drunk each day (up to six cups), the greater the protection. Drinking tea, soda, decaffeinated coffee, or eating chocolate had no protective benefit; probably because these do not contain enough caffeine.

Researchers are quick to say that women should not necessarily order double or triple shots at their local coffee shop and that more research is needed to understand the mechanism of protection. Still, this study confirms earlier research showing that Finnish men who drank large amounts of coffee had a lower risk of depression than those who did not consume coffee. As for us, we will continue to brew a huge pot each morning. Maybe I will try to drink a bit more and get rid of my moniker.

Noted by WVR, MD

*This filler excerpt can be found in the November 2011 Pediatrics print journal p.872, or via online here.

Behavior and Emotional Problems in Offspring: Depressed Mothers Aren’t the Only Contributors — Dad Plays a Role Too!

2011-11-07T00:01:00.000-08:00

So much has been published about the role of maternal depression contributing to behavioral and emotional difficulties in children — but what about dads? Weitzman et al. (doi: 10.1542/peds.2010-3034) studied this association in an early release article we are sharing with you this week. The authors studied almost 22,000 children ages 5-17 years and their parents using various survey tools and questionnaires. When maternal depressive symptoms and other possible variables are controlled for, paternal depression emerges as a factor independently associated with increased rates of behavioral and emotional problems in children. Why and how paternal mental health affects offspring makes for an interesting read that should not be missed. Link into the article and learn more.

Another C for Diamonds

2011-11-04T00:01:00.000-07:00

Dr. William V. Raszka, our Associate Editor, offers the following insight into a current topic in the news:

Most of us have heard of at least three of the four Cs associated with diamonds: cut, clarity, color, and cost. Now there may be another, carbon cycle. While not as glamorous as the first three, scientists are excited in regards to what they can learn about the carbon cycle and the earth’s mantle from impurities found in diamonds. Most diamonds are formed miles beneath the rock under continents. However, some diamonds are made much farther below the earth’s surface and are associated with enormous slabs of rock that were initially part of the ocean floor.

According to an article in The New York Times (Science: September 15, 2011), scientists could detect these slabs, which are approximately 435 miles beneath the surface, in seismic images but could not directly study them as no drill could penetrate to that depth. However, by examining impurities found in diamonds mined in Brazil, they gleaned information about these slabs. The data suggests that a very large and deep conveyer belt exists that recycles carbon between the ocean and the earth’s mantle. As the rock slabs beneath the oceans descended into the earth’s mantle, basalt and traces of organic material on the ocean floor descended with it. When the diamonds formed within these slabs, impurities, originally on the ocean floor became trapped in some of them. Once formed, diamonds eventually reached the surface floating in a plume of molten rock.

Researchers scanned hundreds of non-gem quality diamonds before finding a few that suggested formation at great depths. Using a jeweler’s polishing wheel and spectroscopic tests, the researchers were able to measure the mineral composition of the diamond impurities. They were able to infer the existence of two minerals that can only form under conditions found more than 400 miles below the earth’s surface. Moreover, they could measure the amount of Carbon 13, a signature of organic carbon. The findings change the way we think about plate tectonics.

There is more vertical movement than previously thought. Understanding how carbon is cycled within the mantle could give us a better understanding of our environment. While diamonds with impurities may not be a girl’s best friend, they may be scientists’.

Noted by WVR, MD

*This filler excerpt can be found in the November 2011 Pediatrics print journal p.945, or via online here.

"Warning Signs" To Better Detect Unmet Mental Health Needs

2011-10-28T00:01:00.000-07:00

We know we miss children with mental health needs often, and may not be aware of certain signs or symptoms that may point us in that direction. Fortunately, Jensen et al. (doi: 10.1542/peds.2009-0367) remedy this situation by analyzing epidemiologic data sets involving more than 6,000 children and parents to establish scientifically-derived "warning" or "action signs" that have positive predictive values that could indicate a mental health diagnosis and allow us to institute services sooner rather than later. Just what these warning signs are forms the body of this special article which can be used by not just pediatric clinicians, but also by parents, teachers, and the lay public to insure these children get referred to their primary care pediatric office sooner rather than later for further evaluation and management.

How Much is Enough?

2011-10-28T00:00:00.000-07:00

Dr. William V. Raszka, our Associate Editor, offers the following insight into a current topic in the news:

Many of my friends exercise all the time while others hardly ever. When I ask those not exercising why they don't, most say they don't have enough time, that it is too hard to start, or that exercising just a few minutes a day is unlikely to be beneficial. Exercise physiologists and others have long wondered just how much aerobic exercise each day or each week is necessary to produce a health benefit in adults.

As reported in USA Today (Fitness & Food: August 2, 2011), it turns out that it doesn't take much at all. Federal guidelines suggest that adults should engage in 150 minutes of moderate-intensity activity each week. This is still a reasonable goal. However, new data suggests that almost any amount of exercise may be beneficial. Adults engaging in as little as 10-15 minutes a day of moderate-intensity exercise accrue some benefit in the prevention of heart disease. In studies evaluating the risk of heart disease in sedentary and exercising adults, the most dramatic health benefits were seen in those who went from not exercising at all to exercising a little bit.

The data also show that there is an indirect relationship between the amount of exercise and the risk of heart disease. Compared to sedentary individuals, those who engaged in 150 minutes of moderate-intensity exercise each week had a 14 percent reduced risk of heart disease. Those who exercised 300 minutes each week had a 20 percent risk reduction and a 25 percent risk reduction if they exercised 750 minutes. Women, for unknown reasons, derive a greater benefit to exercise than men. Bursts of activity followed by long periods of inactivity, however, were not beneficial. This suggests that for better health, one needs to keep moving. While researchers have not been able to quantify the exact health benefit to 75 minutes of weekly moderate-intensity exercise, the American College of Sports Medicine recently revised their guidelines.

While the guidelines still recommend adults engage in at least 150 minutes of moderate-intensity exercise each week to achieve weight reduction and help maximize the health benefits of exercise, just a little exercise, such as 75 minutes a week, is likely to be beneficial. The data is fairly clear. To borrow a marketing phrase from Nike: Just Do It.

Noted by WVR, MD

*This filler excerpt can be found in the October 2011 Pediatrics print journal p.752, or via online here.

Bisphenol A Exposure and Problems with Behavior and Executive Function: An Interesting Association

2011-10-26T00:00:00.000-07:00

There are more and more articles in the lay literature as well as in the scientific literature regarding the influence of environmental exposures on children. While causality may not be proven, strong associations are surfacing that are concerning. This week, we share one such set of associations between exposure during gestation and early childhood to bisphenol A and behavior and executive function at 3 years of age. Braun et al. (doi: 10.1542/peds.2011-1335) studied 244 mothers and their 3-year-old children using bisphenol A (BPA) urine concentration and child behavioral assessment. The higher the BPA gestational concentration, the worse the behavior reported, although this effect was greater in girls than boys. Just why this occurs and what it might mean form the basis of an interesting Discussion section that warrants your attention. Reading this study may have you wanting even more environmental studies in our journal to better understand just what compounds like BPA are really doing when they get into our bodies. I welcome your feedback on the BPA controversy via our Facebook page.

Comparing Approaches to Quality Improvement

2011-10-25T00:01:00.000-07:00

Our Quality Reports Editor Dr. Alex Kemper offers the following preview of what’s being published in the newest section of our journal:

Over the past century, there has been tremendous growth in the science of improving manufacturing quality. Some of these methods have been translated to healthcare delivery. For example, in the mid 1920s, Walter Shewhart developed process control charts to identify strategies for telephone systems. Eventually, these methods were adopted by Motorola in the development of Six Sigma, which has been widely adopted into healthcare. Six Sigma refers to reducing variability below six standard deviations (e.g., an error rate of 99.999966% or less) through measurable continuous quality improvement activities supported by effective management. Another example of a quality improvement approach that has been adopted into healthcare is Lean Management, based on the Toyota Production System. "Lean" focuses on improving efficiency by reducing waste and optimizing flow.

Castello et al. (doi: 10.1542/peds.2010-3617) present findings from a project to reduce TPN-associated blood stream infections. Of particular interest to me was the use of Failure Modes and Effect Analysis (FMEA). FMEA has been used by NASA and a variety of other industries. It is based on identifying and categorizing failures across factors including significance and severity, frequency, and how difficult they are to prevent. In my experience, this approach can be especially helpful for rare but serious problems. Of course, there is significant overlap across all of the approaches for quality improvement (e.g., small tests of change, repeat measurement, measurable goals). I think it is instructive to see quality improvement projects based on different underlying approaches. However, it is interesting to wonder whether a different approach would have led to different outcomes.

An "A" By Any Other Name

2011-10-24T00:00:00.000-07:00

Dr. William V. Raszka, our Associate Editor, offers the following insight into a current topic in the news:

The other day, my eldest son shared with me his most recent college grades. He was quite happy that he had all A’s and B’s. While proud of his accomplishments, I was a little perplexed. I knew he worked hard in Japanese but how in the world had he gotten such a high grade in his mathematics course? After all, math classes had been his Achilles heel since middle school. Moreover, my wife, who is a mathematician, had trouble getting A’s in mathematics courses while in college. One explanation could be that my son benefited from college grade inflation.

According to an article in The New York Times (Economix Blogs: July 14, 2011), over the past few decades, the percentage of A grades awarded at colleges has dramatically increased. Reviewing data from 200 four year colleges and universities, researchers found that the percentage of A grades increased from 15 percent to 30 percent between 1940 and 1980 and in 2008 stood at 43 percent. The percentage of B grades has held steady at approximately 35 percent. However, the percentage of C’s and D’s has fallen precipitously. Currently, only about 10 percent of all grades are D’s and F’s. Interestingly, public schools tend to be stingier than similarly selective private schools as only 73 percent of grades at public schools are A’s and B’s compared to 86 percent at private schools. Science and engineering schools tend to grade harder than liberal arts schools.

Why the grade inflation? Initially, back in the 1960s professors may have not wanted to fail students as failing students could be sent to Vietnam. The recent dramatic increase is more likely due to an incentive driven approach to education. Courses with more lenient grading curves tend to get better instructor reviews. Moreover, many schools want to maximize the success of graduating students competing for jobs or graduate school programs. Of course, with so many students all reporting A’s and B’s, the challenge for employers or graduate schools to identify truly superior students is made only more difficult.

As for my son, I opted not discuss with him grade inflation or how in my wife’s mathematics program the average student, regardless of the difficulty of the course, was awarded a C. We simply enjoyed the moment and the fact that he had worked quite hard and to the best of his ability.

Noted by WVR, MD

*This filler excerpt can be found in the October 2011 Pediatrics print journal p.701, or via online here.

Profanity Use and Teen Aggression: What the #$%& Is Going On?

2011-10-21T00:00:00.001-07:00

It is rare nowadays to not hear profanity expressed on television, in movies, and on videos seen on the internet -- even when the rating is PG -- and in turn to hear more profanity used routinely by adults and adolescents. So are there social ramifications of using foul language in routine conversation? Coyne et al. (doi: 10.1542/peds.2011-1062) attempt to answer that question by studying subsequent behaviors (e.g. aggression) and attitudes related to profanity in more than 200 adolescents via questionnaires. The authors found some disturbing associations between exposure to profanity, frequent use of profanity and aggressive behaviors. You'll curse yourself if you don't read this study and then share the results with your teenage patients and their families.

HPV Vaccine: It May Be Easily Available But Many Teen Females Are Still Not Receiving It

2011-10-21T00:00:00.000-07:00

For several years now the human papillomavirus vaccine has been available and part of the recommended vaccination schedule for older children and teenagers. So how are we doing in getting this vaccine administered? Dorell et al. (doi: 10.1542/2011-0950) attempt to answer that question by reviewing data from the 2008 and 2009 National Immunization Survey. The results, though suggesting that coverage is increasing yearly, are still disappointing with less than half of eligible females receiving at least one dose and less than half of these getting the full series. There are multiple reasons why our patients are not getting this vaccine (and have even been attributed to off the cuff comments from presidential candidates who appear to need more education themselves on the benefits versus risks of the vaccine). Our lack of success as pediatricians to educate parents and recommend this important prevention strategy certainly leads the list. Make sure your teenage patients (and their families) know about the importance of this vaccine and in turn receive it. Doing otherwise is not in the best interest of our patients.

Parents of Preterm Infants in the NICU Need to Talk the Talk For Their Babies to Do Likewise

2011-10-19T00:00:00.001-07:00

We certainly recognize how valuable it is to read aloud to babies beginning in early infancy -- but how many parents talk to their preterm babies in neonatal intensive care units (NICUs) -- and when they do, does it make a difference? Caskey et al. (doi: 10.1542/peds.2011-0609) tried to address these questions in an interesting study being released this week. The authors followed a cohort of preterm infants <= 1250 grams and monitored adult word counts relative to infant vocalizations and the results are worth talking about! When parents talk, their babies listen, and talk back a lot sooner than infants of parents who simply sit by their babies and say less. These differences are specific to parents and not others who spend time taking care of preterm babies. The benefits of talking to your preterm baby in the NICU are fully elaborated upon in the discussion section of this paper. This study is well worth sharing with expectant parents during a prenatal or newborn visit, whether it occurs in the well baby nursery or in the NICU.

Innovations in Immunization Reminders: Are Cell Phone Text Messages the Future?

2011-10-19T00:00:00.000-07:00

With more and more of our patients and parents using text messaging , it seems only natural that we use this technology to remind our patients that they need to come in for routine immunizations at the appropriate time. Yet, do parents prefer to get their reminder by cell phone or text, or is a conventional mailed letter or personal phone call to home still what parents want? Clark et al. (doi: 10.1542/peds.2011-0270) go online this week with the results of a cross-sectional internet-based survey of a nationally representative sample of parents and the results suggest that the majority of patients are not yet ready for texting as the communication strategy of choice. Nonetheless, about 25% want to use newer technologies and perhaps in the diffusion of change innovation, these early adopters will lead the way with texting reminders from your office. Remind yourself to read this study and then consider asking your own patients whether they are ready to have you text them for their next health maintenance appointment. Before long your patients may be twittering with excitement about the possibility!

Being the Decider

2011-10-18T00:00:00.000-07:00

Dr. William V. Raszka, our Associate Editor, offers the following insight into a current topic in the news:

I was at dinner the other night trying to decide what to eat. A group of us had just finished a long day of work and were now ready for a much anticipated dinner together. I had a lot of trouble deciding between the fish and meat. Many of my colleagues had similar difficulties deciding on different aspects of the dinner. Why did we have so much trouble? After all, we had made dozens of decisions during the day and everything on the menu looked terrific.

According to an article in The New York Times (Magazine: August 17, 2011), we may have been suffering from decision fatigue. It turns out that making decisions takes a certain amount of mental energy. Each decision takes a toll. Over the course of a day, mental fatigue sets in and each subsequent decision becomes harder. Eventually, the brain may look to take shortcuts. One shortcut is to act impulsively without using mental energy to consider the consequences. We are all familiar with outcomes of such behavior. The other shortcut is to do nothing. While that may temporarily help, in the long term the problem remains. Also reported in the article, a dramatic example of decision fatigue was found among judges.

In a study analyzing more than 1,100 decisions by parole board judges over one year, the timing of the court case had a tremendous impact on the judge’s decision. Prisoners who appeared before the parole board early in the morning were seven times more likely to be granted parole than those who appeared late in the day. The authors concluded that the judge had experienced decision fatigue and opted to do nothing, e.g. did not release a potentially dangerous person into society. While I eventually happily decided to order the meat for dinner, the larger issue for me was to remember that I needed to address bigger issues or more complicated patients earlier rather than later in the day.

Noted by WVR, MD

*This filler excerpt can be found in the October 2011 Pediatrics print journal p.684, or via online here.

There's No Place Like the Medical Home When It Comes To Developmental Surveillance

2011-10-17T00:00:00.000-07:00

Despite the emphasis on developmental surveillance as being a critical component of a child health maintenance visit, only half of U.S. parents self-report they are being asked about their infant or child's developmental concerns during pediatric health maintenance visits -- at least based on a concerning study by Guerrero et al. (doi: 10.1542/peds.2011-0030) being early released online this week. The authors used the National Survey of Children's Health database and found substantive disparities in who is being asked about their child's development based on differences in ethnicity, socioeconomic status, language spoken, and the presence or absence of a medical home. The good news is that when the medical home is in place, the disparities narrow. This study should have us all self-reflecting on how routinely developmental surveillance is or should be in our practices. The sooner we have medical homes established for all patients, the better our ability to not only detect developmental delays, but to intervene and improve them. Perhaps this study should be one of the catalysts to make universal access to medical homes for children become a reality.

The New Arms Race

2011-10-14T00:00:00.001-07:00

Dr. William V. Raszka, our Associate Editor, offers the following insight into a current topic in the news:

Recently, I was trying to book a hotel room in Montreal. The hotel where I usually stay had no available rooms. I selected a few hotels to view and then scanned review sites to see what other travelers had written about them. I was stunned by the diversity of comments. How could one reviewer write the experience was an absolute delight while another said the rooms were tiny, noisy, and poorly ventilated? After looking at several sites, I came to the conclusion that many were simply not useful.

According to an article in The New York Times (Technology: August 19, 2011), writing reviews has become an arms race. As more and more people depend on the Web as a source of information, retailers, hoteliers, and publishers depend on reviews to help promote sales. Positive reviews lead to better sales so merchants are looking for more of them. The need for positive reviews has spawned an entire industry of “reviewers” who will publish them for a small sum. Evidently, individuals as well as organizations hire themselves out as professional positive review writers. Spotting genuine from fake reviews is difficult. In a study that compared 400 fake positive reviews of Chicago hotels and 400 reviews thought to be real, individuals could not tell the difference between the two. Researchers who claim to have developed an algorithm that may detect up to 90 percent of fake positive reports have garnered the interest of national retailers who are interested in separating fact from fiction.

According to the researchers, fake positive reviews of hotels tend to be laden with superlatives but not actual descriptions. This is not surprising given that the reviewer has not actually been to the hotel. Moreover, the reviewers tend to write about the experience in the city rather than the hotel and use the words ‘I” and “me” a lot. The merits of a positive review gets even murkier when one realizes that even experienced reviewers for sites such as Amazon don’t have to disclose that they often get free merchandise for their reviews. While reviews on the web tend to be positive, one can find plenty of negative reviews particularly for restaurants. It turns out these are often posted by rivals. So how is a traveler supposed to discern a good restaurant or hotel from one that is not? I tend to rely on my friends. They are unlikely to recommend one that serves lack-luster food or provides poor service.

Noted by WVR, MD

*This filler excerpt can be found in the October 2011 Pediatrics print journal p.636, or via online here.

Chest Pain in Children: Not a Heart-Breaking Problem

2011-10-14T00:00:00.000-07:00

We certainly know that when a child complains of chest pain, we need to take that complaint seriously. Yet how often is chest pain in children a harbinger for a serious cardiac problem? Saleeb et al. (doi: 10.1542/peds.2011-0408) address this question by looking at a decade's worth of patients (n=3700) with a mean age of 13.4 years seen at Children's Hospital Boston for chest pain. The results reveal a variety of diagnoses worth reading about, but only 39 (1%) had a cardiac etiology and no patient over a total of 18,000 patient years died as a result of sudden cardiac death after presenting with chest pain. You can certainly take heart and can reassure your patients, that unlike in adults, serious cardiac disease is unlikely.

NIAID-Sponsored 2010 Guidelines for Managing Food Allergy: Applications in the Pediatric Population

2011-10-13T00:00:00.000-07:00

This week Dr. Phyllis Dennery, Professor of Pediatrics and Chief of the Division of Neonatology at the Children’s Hospital of Philadelphia and University of Pennsylvania, and Associate Editor for our State of the Art articles includes the following information regarding a most interesting article:

Why does it seem that parents, daycare workers, teachers and of course primary care providers and specialists, are frequently challenged with concerns of food allergies in our pediatric population? It seems as if these have become more common in the last decades. The food industry also struggles with issues of labeling and cautionary statements to avoid liability. This month’s State of the Art Review by Burks et al. (doi: 10.1542/peds.2011-0539) examines new guidelines sponsored by NIAID for food allergies in the population as a whole and frames these for the pediatric population. This is obviously a timely topic which should make for provocative reading, as most of us have differences of opinions on approaching this ever-growing problem. This article focuses on the best evidence available to guide practitioners in their management of children with food allergies.

UTIs and Chronic Kidney Disease: Not the Cause and Effect You May Have Thought It Was

2011-10-12T00:00:00.000-07:00

I am particularly fond of articles that provide evidence to support or not support what up to now has been otherwise an unproven assumption truism. Such is the case in terms of our concern for years that having urinary tract infections (UTIs) can lead to chronic kidney disease (CKD). However, Salo et al. (doi: 10.1542/peds.2010-3520) prove that last statement is not necessarily true based on a systematic literature search and a retrospective case series from one hospital looking for but not finding an association between childhood UTIs and CKD. This is reassuring news and supports the less invasive diagnostic and therapeutic recommendations of the AAP's new UTI guidelines (doi: 10.1542/peds.2011-1330) that were published in the September issue of our journal. To better understand how to interpret the findings of this study, we are also including a commentary by Craig and Williams (doi: 10.1542/peds.2011-2631) that will frame the results relative to our prior existing beliefs. So if a UTI is not the cause of CKD, what is? To learn the answer to this question, go with the flow (so to speak) and read the findings of the Salo study and Craig's insightful commentary, which combined with the new UTI guidelines will almost certainly change the way we practice.

Paper or Electronic?

2011-10-11T00:00:00.001-07:00

Dr. William V. Raszka, our Associate Editor, offers the following insight into a current topic in the news:

A few weeks ago I purchased a pair of shorts at a local clothing store. I paid using a credit card. At the end of the transaction, the nice young cashier asked if I would like a paper receipt or one emailed to me. Maybe I don’t do enough shopping these days, but I was little surprised. I had always gotten a paper receipt.

As reported in The New York Times (Technology: August 7, 2011), however, electronic receipts are likely the way of the future. Many major retailers now routinely offer customers the option of an electronic or paper receipt. More and more often, customers are opting for the electronic version. While the technology for paperless receipts has been available since the 1990s, Apple was one of the first major retailers to adopt the technology beginning in 2005.

While some retailers have had difficulties offering electronic receipts, given that fairly soon many customers will be purchasing products with their Smartphone, it seems only logical that the paper receipt will become a relic of the past. The advantage to consumers is clear. Electronic receipts can easily be stored, referenced at a later date, and if necessary, printed anywhere. For retailers, costs are lower and less paper consumed. At some stores, roaming clerks can check out customers as soon as the customer is ready wherever they may be in the store adding to customer satisfaction. More importantly, the electronic receipt can be used for marketing purposes. Not only can messages or images be attached to the receipt but once the email address of a customer is known, the email can be used for targeted, marketing purposes.

As for me, while I like the concept of an electronic receipt from a brick and mortar store, I hate the idea of giving my email to yet another corporation who will use it to send me dozens of emails extolling the virtues of the many wonderful deals being offered. I opted not change my behavior, declined to give her my email address (or telephone number), and stuffed the paper receipt into my wallet with the others.

Noted by WVR, MD

*This filler excerpt can be found in the October 2011 Pediatrics print journal p.774, or via online here.

Two Vaccine Studies Take Their Best Shot At Reducing Influenza Risk

2011-10-11T00:00:00.000-07:00

With influenza season soon to be upon us, it is reassuring that the use of the annual targeted vaccine has a great track record of reducing the incidence and severity of influenza in children. Yet, while two doses of vaccine are recommended when first vaccinating a child, often only one is administered before a child is exposed. Is the one dose at all effective in reducing severity of influenza in terms of hospitalizations? Gilca et al. (doi: 10.1542/peds.2010-3492) performed a case-control study and demonstrate that even a single dose of vaccine given to children 6 months to 9 years of age can be quite protective if given at least 10 days before the onset of illness. Does this mean only one dose is sufficient? Not exactly, but it does mean that giving at least one dose is better than giving none.

We also know that while babies are often a captive audience for getting the vaccine, administering it to older children and teens is not as easy. So is it better to consider vaccinating teens against influenza at school or in their primary care office? Gargano et al. (doi: 10.1542/peds.2011-0453) tackle this question using a non-randomized three county cluster study where school-based vaccine was given in one county, provider-based in a second, and standard of care (both) in a third county. The results demonstrate that neither school nor office shows dramatic success, but the opportunities to increase vaccination rates may rest more with improved vaccine education. One setting is clearly better than the other in this particular study. Take a shot at reading both studies to be up-to-date in terms of new knowledge about effectiveness as well as the best way to insure adequate vaccine coverage in your community.

Real-time Polymerase Chain Reaction for Diagnosing Acute Respiratory Infections in Children: Do They Reduce Hospital Admissions and/or Length of Stay

2011-10-10T00:00:00.001-07:00

The use of real-time polymerase chain reaction (rt-PCR) is one of the more exciting diagnostic strategies for those of us who care for acutely ill children with acute respiratory symptoms. The prospect of using them to make a diagnosis and in turn reduce unnecessary hospitalizations, length of inpatient stay, and /or use of unnecessary antibiotics makes us very eager to learn about these tests and their cost-effectiveness. Yet, we also know that running these tests still take several hours -- longer than the average emergency room stay that results in a triage decision to admit or send a patient home. This week, Wishaupt et al. (doi: 10.1542/peds.2010-2779) share with us the benefits of using a 16 pathogen rt-PCR to make a more accurate diagnosis and report on whether or not knowing the results of the PCR leads to less costly hospitalizations or a decrease in prophylactic antibiotic coverage. The results will likely underwhelm you, at least in 2011, but also excite you about the prospects that as these assays get faster, their ultimate cost-effective benefits will begin to appear.

Testing for Fetal Gender

2011-10-07T00:00:00.000-07:00

Dr. William V. Raszka, our Associate Editor, offers the following insight into a current topic in the news:

My wife and I have four children. Each pregnancy was marked by joy, eager anticipation and many, many long discussions trying to decide on a name for our child. We had to pick out names for both girls and boys as we had always instructed the obstetrician doing the prenatal ultrasound not to reveal the sex of the fetus. While our discussions were not quite as bitter as those between Democrats and Republicans in Congress, they did last a long time and were marked by twists, surprises, and compromises. It turns out, however, that couples can save themselves some trouble.

As reported in The New York Times (Health: August 9, 2011), a recently published systematic review and meta-analysis of noninvasive fetal sex determination testing in approximately 6,500 pregnancies found that properly performed tests had > 95 percent sensitivity and specificity at 7 weeks gestation and 99 percent sensitivity and specificity at 20 weeks gestation. The review focused on tests that detect and amplify cell free fetal DNA in maternal blood. The test kits generally use PCR to detect the fetal Y chromosome in a few drops of maternal blood. Detection of the Y chromosome confirms a male infant. Failure to detect the Y chromosome indicates that the fetus is a girl or possibly, that no fetal DNA was present in the sample. While the kits have been available for several years, they are not regulated by the Food and Drug Administration and some have been plagued by poor specificity. The fetal DNA test kits are likely to be used by parents and physicians worried about sex-linked diseases such as Duchenne muscular dystrophy, and those just anxious to know the sex of their child a little earlier.

While not usually an issue in the United States, because the kits can be used to select the sex of offspring, some manufacturers do not sell the kits in India or China where boys are favored over girls. While the tests are non-invasive, the total cost can be quite high. The test kit itself may cost $25 but once shipping and laboratory fees are calculated, the total cost may be closer to $250. As for us, we were fortunate that we did not have to worry more than usual about gender-linked illnesses, and the surprise of seeing each of our new arrivals greet us in the delivery room regardless of gender was priceless.

Noted by WVR, MD

*This filler excerpt can be found in the October 2011 Pediatrics print journal p.722, or via online here.

A Nibble A Day

2011-10-05T00:00:00.002-07:00

Dr. William V. Raszka, our Associate Editor, offers the following insight into a current topic in the news:

What do you eat before exercising? Some experts and trainers advocate high quality protein, complex carbohydrates, or sometimes, even simple sugars. Has anyone ever recommended eating chocolate before exercising? If not, that could change. According to an article in The New York Times (Health: August 3, 2011), chocolate may improve exercise performance. Researchers conducted a study in middle aged, sedentary mice. Twice a day, the experimental mice were given small doses of purified epicatechin, a flavonol and the primary ingredient of cacao in chocolate. Control mice were only given water. Groups were further divided into those that did light exercise and those that did not. After 15 days, all animals were run to exhaustion on a treadmill and then underwent hind leg biopsy. Animals that had only been given water were the first to tire.

Surprisingly, control mice who had exercised, tired more quickly than the non-exercising mice who had received epicatechin. Mice that exercised and consumed epicatechin were the fittest and could run 50 percent farther than the others. Leg muscle biopsies revealed that the exercising mice given epicatechin demonstrated rich new capillary growth and evidence of increased mitochondria production. Those mice only given epicatechin still had evidence of new mitochondria production. This suggests that epicatechin had beneficial effects in sedentary rodents and that exercise greatly magnified the benefits. Exactly how epicatechin improves the mouse’s muscle response to exercise is not known. Whether this effect will be seen in humans is also not known. While it may be tempting to gulp down a chocolate bar before a long run, a few caveats should be kept in mind. Processing tends to destroy the epicatechin in chocolate. Dark chocolate contains far more epicatechin than heavily processed milk chocolate.

Unfortunately, for those of us who love dark chocolate, a little goes a long way and more is not better. Based on the mouse study, the average person only needs about 5 grams of chocolate before exercising. As my wife would say, that is less than a bite and more in line with just a nibble. The hardest part may not be the ensuing run but refraining from eating the rest of the bar.

Noted by WVR, MD

*This filler excerpt can be found in the October 2011 Pediatrics print journal p.672, or via online here.

A New Therapy For Recalcitant Osgood-Schlatter Disease: Hyperosmolar Dextrose

2011-10-05T00:00:00.001-07:00

We are so used to using tincture of time, rest, and reassurance to treat our adolescent patients with Osgood-Schatter Disease. Yet, what options do we have if usual "routine care" doesn't work? Lidocaine injection into the inflamed knee (the apophysis and paellar tendon) has been a possibility, but recently a new therapy has been pilotedhyperosmolar dextrose. Topol et al. (doi: 10.1542/peds.2010-1931) performed a randomized controlled trial of injected dextrose versus lidocaine (with or without dextrose) versus routine care in a very interesting study being released this week. The results are dramatic and could change how we deal with refractory Osgood-Schlatter Disease. Bone up on this study and perhaps discuss it with your local pediatric sports medicine colleague to see if they or you are game enough to try it (or whether you want even more patients to demonstrate a benefit than just the 65 knees enrolled in one of the arms of this study).

The Alternative Vaccine Schedule: Don't Try This In Your Office -- Yet Many Still Do!

2011-10-05T00:00:00.000-07:00

There has been much written about the risks versus the benefits of using an alternative vaccine schedule at parental request in order to reduce the risk of complications of vaccines (or that's what parents who ask for this seem to believe). Even our journal has weighed in on this topic with a special article (doi: 10.1542/peds.2008-2189) pointing out the problems with an alternative vaccine schedule in our Janaury 2009 issue. So how are we doing convincing parents not to use this delayed vaccination schedule? This week Dempsey et al. (doi: 10.1542/peds.2011-0400) attempt to answer that question via data obtained from a cross-sectional web-based national survey of parents of children 6 months to 6-years-old. The somewhat disheartening results suggest that not only are 10% of parents opting to delay vaccines in their children, but even more families are jumping on that bandwagon. Clearly, we have work to do. You will certainly want to peruse the results of this study and consider reading or re-reading Dr. Offit's special article so as to better educate your patients to avoid putting their children at increased risk for what might otherwise be a preventable infection.

Ceftriaxone-Induced Hemolysis in a Child With Lyme Arthritis: A Case for Antimicrobial Stewardship

2011-10-04T08:25:00.000-07:00

Our Case Report Associate Editor Dr. Jeff Malatack shares with us his excitement learned from a case report we are early releasing this month from our upcoming November issue:

An article by Boggs et al. (doi: 10.1542/peds.2010-1570) brings to our attention a case of Ceftriaxone induced hemolysis that led to renal failure in an 11-year-old female with Lyme disease. The authors then review the literature and quote a sobering mortality of nearly 50% of those who developed drug induced hemolytic anemia complicating Ceftriaxone therapy. Other therapy options in this patient could have included oral therpy with doxycycline. The patient reported did well fortunately, but the report should give everyone pause. Cetriaxone (or “Vitamin C” as it has come to be known in Pediatric EDs) is used with remarkable and excessive frequency in emergency departments. Bogg's patient clearly had tertiary Lyme disease and warranted this treatment and the risk of this rare complication. Many others, over-diagnosed with Lyme disease when that is not the etiology for the patient’s symptoms, as well as other conditions that don't warrant such therapy, are at risk of this potentially lethal complication. What is most concerning to ponder is that they may be put at risk for this drug reaction all too often without a clear diagnosis warranting the use of this antibiotic. Hopefully by reading this case report, you’ll continue to be a prudent steward of appropriate antimicrobial usage (as was the case in this interesting article). Read it and learn more!

Increased Risk of Learning Disabilities Following Anesthesia Exposures: A Troubling Association Identified

2011-10-03T00:00:00.000-07:00

Nothing is more essential when undergoing surgery than to be pain-free during the procedure, thanks to the benefits of anesthesia and a pediatric-trained anesthesiologist. Yet, the same drugs that anesthetize have been found with repeated use to cause apoptotic neurodegeneration in immature animals. This is noted by Flick et al. (doi: 10.1542/peds.2011-0351) in an early release article that studies a cohort of children with and without learning disabilities who did and did not get anesthesia before the age of 2. Exposure to multiple but not single anesthetics was associated with an increased risk of developing a learning disability, confirmed by tests of achievement and cognition. Needless to say, the results, though methodologically sound, are troubling and should be cautiously interpreted at least as per an accompanying commentary by Dr. Robert Williams (doi: 10.1542/peds.2011-2489). This is an important study to read and learn about, given that the national media are likely to tell your patients about this study if you don't do it first. As per the commentary, the benefits of anesthesia far outweigh the risks as reported in this article, but nonetheless one cannot ignore the fact that we will need to know which agents are the least neurotoxic when it comes to using the right drugs to relieve pain in our youngest patients.

Neonatal Sepsis Evaluation: Are Molecular Assays Changing the Culture?

2011-09-30T00:01:00.000-07:00

It is becoming more and more common to not just obtain microbial cultures on a potentially septic neonate, but also to send various body fluids for molecular assays such as polymerase chain reaction (PCR) studies directed against a particular organism. But just how good are these assays? While they give us faster results, one needs to make sure the sensitivity and specificity are good enough to replace cultures. To help us sort out the evidence these new assays, Pammi et al. (doi: 10.1542/peds.2011-1208) have performed a systematic review of the literature and a meta-analysis of results from the studies they have culled. While you may not give up sending cultures to the lab just yet, you might consider using these assays in an "add on" way under particular circumstances. To better understand the risks and benefits of molecular assays, and to be more cost-effective in their use, take a few minutes to assay this important review article.

Intermediate Uveitis and Alopecia Areata: Is There a Relationship? Report of 3 Pediatric Cases

2011-09-29T00:01:00.000-07:00

Our Case Report Associate Editor Dr. Jeff Malatack shares with us his excitement learned from a case report we are early releasing this month from our upcoming October issue:

A Dutch group led by Dr. Ayuso (doi: 10.1542/peds.2011-0142) report a case series of three patients ages 5, 8, and 15 with the combination of Intermediate Uveitis (IU) and Alopecia Areata(AA). We learn that IU is the second most common form of uveitis and affects the vitreous compartmnet of the eye. The observation appears to be the first connection these two presumed autoimmune processes. Both IU and AA are thought to be T cell mediated immune defects. When one considers that both visual loss and patchy hair loss are symptoms that rarely go ignored and are usually brought to attention of medical care deliverers quickly, one can't help but wonder where were the previous cases, and why is this condition being reported only now? Perhaps others have seen these conditions in combination and choose not to report them, or perhaps something in the environment that contacts both the skin and the eye is sensitizing and creating this via our Facebook page as well as through eLetters to report prior known but unreported cases of this association. If there is no prior known association, with apologies to Lewis Carrol, it is getting curiouser and curiouser.

Soda Revival

2011-09-28T00:01:00.002-07:00

Dr. William V. Raszka, our Associate Editor, offers the following insight into a current topic in the news:

“The sodas were really good,” said my wife. She was talking about the carbonated drinks that a friend of the family had made for her that evening. We don’’t drink much soda in our house so my wife’’s enthusiasm was surprising. When she suggested that we should investigate purchasing a small home soda making system, I was pretty much floored. “"You can mix all kinds of syrups and flavors”" she explained. Little did she realize that not only was she describing soda production at the turn of the 20th century, but also my father’’s first job.

In the early 20th century, refrigeration was still uncommon. Fizzy water was a novelty and associated with curative medicinal powers. People looking for a refreshing drink could order any one of myriad sodas, or carbonated beverages, from a store that had a soda fountain - the machine that carbonated the fluid. The soda makers were called soda jerks, a title that my father still wears proudly, because of the motion they made while mixing the drink. Before iceless refrigeration became more commonplace the drinks were initially chilled with blocks of ice. Once carbonated beverages could be easily capped and people could buy a soda almost anywhere, the job of the soda jerk disappeared. So did much of the variation in sodas.

However, according to an article in The New York Times (Dining: July 5, 2011), soda fountains and soda jerks may be making a small comeback, particularly in large metropolitan centers. Modern soda jerks have embraced the locavore movement and offer high quality seasonal, home-made, locally sourced drinks often with eclectic flavors. Instead of serving a cola drink, modern soda jerks may create new drinks incorporating vanilla, milk, olive oil, and salt or recreate old fashioned recipes with phosphoric acid and tea. Regardless of the flavor, all soda jerks agree that a soda fountain must have a carbonator and taps as that is the only way to generate vigorous bubbles.

As for us, we have yet to purchase a home carbonator system, but I certainly have enjoyed discussing sodas with my father. As a former expert soda jerk, he promises to teach me how to make flips, fizzes, ades, yips, and even malts. I am not sure what they all are, but I am certainly willing to try them.

Noted by WVR, MD

*This filler excerpt can be found in the September 2011 Pediatrics print journal p.552, or via online here.