Family dynamics in families with very low birth weight and full-term infants: a pilot study

The purpose of this pilot study was to determine differences in family health across six dimensions of functioning between families with a very low birth weight infant (VLBW) and families with a full-term infant. An epidemiologic model and Barnhill's (1979) system theory of healthy family dynamics provided the organizing framework for the study. Sixteen families with a VLBW infant and 25 families with a full-term infant were assessed for differences in family health across Barnhill's six dimensions. Independent t-tests showed no significant differences on the five dimensions of infant behavioral style. While a 2 x 3 MANOVA showed no significant differences on any of the measures by family, the Turkey HSD post hoc tests for main effect found significant differences related to the mothers' position within the family, Specifically, the position the mother maintains in the family significantly contributes to certain dimensions of family health.

Evaluating minority recruitment into clinical studies: how good are the data?

PURPOSE

There has been much publicized concern about difficulty with minority recruitment into research studies, particularly since minority inclusion in randomized clinical trials was mandated by the 1993 National Institutes of Health Revitalization Act. We reviewed recruitment data in published reports from clinical studies to assess the actual degree of success in recruiting minorities versus whites and to identify barriers to recruitment.

METHODS

We abstracted articles published between September 1993 and February 1995 that reported detailed results of participant recruitment for studies conducted in the United States.

RESULTS

Of 65 articles meeting our eligibility criteria (median sample size, 1323), only one (1.5%) reported the racial/ethnic composition of potential study participants. Only two articles (3.1%) provided information about the racial/ethnic composition of eligible subjects, and only one (1.5%) provided information about the racial/ethnic composition of refusing subjects. For enrolled subjects, race/ethnicity was less likely to be reported (58.5%) than were age (90.8%) or gender (80.0%).

CONCLUSIONS

The published literature currently contains insubstantial data to either refute or prove that there are differential recruitment rates among minorities as compared with whites. Changes in reporting will be needed in order to track progress in this area.

Effects of debittering on grapefruit juice acceptance

This study was conducted to assess the acceptance of grapefruit juice which has undergone a debittering process. The sensory effect of debittering and the sensory attributes of sourness, sweetness, bitterness, and aftertaste were appraised, and the correlation between chemical and sensory analyses of the debittered juice were identified. The effect of added grapefruit flavor on perception of sweetness and sourness was statistically significant. Both the level of bitterness and storage duration of grapefruit were shown to influence the way judges perceived bitterness and sweetness. Storage study showed no difference in aftertaste, which may increase consumers buying interest in debittered juice with a high level of bitterness (450 ppm).

Silicone-covered Wallstent prototypes for palliation of malignant esophageal obstruction and digestive-respiratory fistulas

BACKGROUND

Endoscopic palliation of malignant esophageal obstruction with uncovered self-expanding metal stents has been shown to have fewer complications than with conventional plastic stents. The addition of a membrane might prevent tumor ingrowth and allow treatment of digestive-respiratory fistulas. We report the clinical experience with a prototype silicone membrane-covered self-expanding metal stent.

METHODS

Twenty-three silicone membrane-covered Wallstent prototypes were used in 21 patients with dysphagia due to inoperable malignant tumors involving the esophagus and cardia.

RESULTS

Stent implantation was technically successful in all patients. There were no procedure-related perforations or deaths. The prototype stent was successful in sealing seven of the eight (87.5%) digestive-respiratory fistulas. As a group, the mean dysphagia grade improved significantly after stent placement (4.8 +/- 0.9 vs 3.4 +/- 1.6, p < 0.0005). However, 9 of 21 (42.9%) patients experienced no improvement in their dysphagia. Complications occurred in 13 of 21 (61.9%) patients. Tumor ingrowth was not observed in any patient.

CONCLUSIONS

The prototype covered self-expanding metal stent was effective in sealing digestive-respiratory fistulas and provided palliation of dysphagia in slightly more than one half of the patients studied. A great deal has been learned from the preliminary experience, which has led to design modifications. The utility of the commercially available device should be evaluated in further prospective clinical trials.

Complications of endoscopic biliary sphincterotomy

BACKGROUND

Endoscopic sphincterotomy is commonly used to remove bile-duct stones and to treat other problems. We prospectively investigated risk factors for complications of this procedure and their outcomes.

METHODS

We studied complications that occurred within 30 days of endoscopic biliary sphincterotomy in consecutive patients treated at 17 institutions in the United States and Canada from 1992 through 1994.

RESULTS

Of 2347 patients, 229 (9.8 percent) had a complication, including pancreatitis in 127 (5.4 percent) and hemorrhage in 48 (2.0 Percent). There were 55 deaths from all causes within 30 days; death was directly or indirectly related to the procedure in 10 cases. Of five significant risk factors for complications identified in a multivariate analysis, two were characteristics of the patients (suspected dysfunction of the sphincter of Oddi as an indication for the procedure and the presence of cirrhosis) and three were related to the endoscopic technique (difficulty in cannulating the bile duct achievement of access to the bile duct by "precut" sphincterotomy, and use of a combined percutaneous-endoscopic procedure). The overall risk of complications was not related to the patient's age, the number of coexisting illnesses, or the diameter of the bile duct. The rate of complications was highest when the indication for the procedure was suspected dysfunction of the sphincter of Oddi (21.7 percent) and lowest when the indication was removal of bile-duct stones within 30 days of laparoscopic cholecystectomy (4.9 percent). As compared with those who performed fewer procedures, endoscopists who performed more than one sphincterotomy per week had lower rates of all complications (8.4 percent vs. 11.1 percent, P=0.03) and severe complications (0.9 percent vs. 2.3 percent, P=0.01).

CONCLUSIONS

The rate of complications after endoscopic biliary sphincterotomy can vary widely in different circumstances and is primarily related to the indication for the procedure and to endoscopic technique, rather than to the age or general medical condition of the patients.

Major hemorrhage from endoscopic sphincterotomy: risk factor analysis

We carried out a retrospective cohort study on all patients undergoing sphincterotomy at our institution over a 4-year period. Major hemorrhage occurred in 10 of 189 patients (5.3%). Onset was usually delayed (mean, 3.0 days; range, 0-9 days). Six potential risk factors for postsphincterotomy hemorrhage were assessed by univariate and multivariate analysis. Three factors predicted postsphincterotomy hemorrhage: hemodialysis (relative risk, 8.4; 95% confidence interval, CI, 2.7-26.4), a prothrombin time prolonged at least 2 s above control (relative risk, 7.8; 95% CI, 2.4-25.6), and endoscopically observed bleeding at the time of sphincterotomy (relative risk, 5.9; 95% CI, 1.7-20.1). Features not independently associated with hemorrhage were sphincter of Oddi dysfunction, aspirin or nonsteroidal anti-inflammatory drug (NSAID) use within 1 week prior to sphincterotomy, and sphincterotomy length. When differentiated from endoscopically observed bleeding, clinically significant hemorrhage was usually a delayed complication, primarily in patients with hemostatic defects.

Alginates. A "new" dressing alternative

BACKGROUND

Currently, a wide variety of bio-occlusive dressing materials are available. In general, these dressing materials provide a moist wound healing environment that has been shown to promote healing in both human and animal studies. To effectively use these dressings the clinician must have a full understanding of the properties of the materials as well as the pathophysiology of the particular wound. Most recently, a "new" biosynthetic dressing material, the alginates, has become available.

OBJECTIVE

To highlight proper use of alginate dressings for the management of acute and chronic wounds.

METHODS

Case study and literature review.

RESULTS

Alginates were shown to be effective in a wide variety of acute and chronic wounds.

CONCLUSION

Alginates possess several unique properties that should prove useful to the dermatologic surgeon as well as the dermatologist. Proper patient selection and use of this "new" dressing material, as well as a review of the literature is presented.

Cephalexin and penicillin in the treatment of group A beta-hemolytic streptococcal throat infections

OBJECTIVE

To determine whether cephalexin or penicillin is more effective in the treatment of group A beta-hemolytic streptococcal tonsillopharyngitis in children.

DESIGN

Randomized, double-blind, crossover study conducted from 1981 to 1984.

SETTING

Seven pediatric practices in the United States, including private offices and pediatric clinics.

PARTICIPANTS

Of the 654 patients, 525 children and adolescents with clinical evidence of tonsillitis or pharyngitis and throat cultures positive for group A beta-hemolytic streptococcal infection were evaluable. Eighty percent of patients completed the study; none were withdrawn because of adverse reaction.

SELECTION CRITERIA

Children and adolescents who had acute illness suggestive of group A beta-hemolytic streptococcal infection were enrolled in the study. Treatment was continued if the throat culture was positive for group A beta-hemolytic streptococcal infection.

INTERVENTIONS

Four doses of cephalexin and penicillin (27 mg/kg per day) were prescribed to be taken on an empty stomach for 10 days.

MEASUREMENTS/MAIN RESULTS

Symptomatic clinical failure occurred in 8% of penicillin-treated patients and in 3% of cephalexin-treated patients. Bacteriologic failure rates were 11% in the penicillin treatment group and 7% in the cephalexin treatment group. The combined treatment failure rate of clinical relapse plus asymptomatic bacteriologic failure was 19% in the penicillin treatment group and 10% in the cephalexin treatment group. Paired antistreptolysin-O titer increased significantly in 62.3% of penicillin-treated patients and in 64.2% of cephalexin-treated patients. Similarly, anti-DNase B titers rose 52.2% in penicillin-treated patients and 52.4% in cephalexin-treated patients.

CONCLUSION

Cephalexin is a more effective drug than penicillin in the treatment of group A beta-hemolytic streptococcal throat infection in children.

Sterile endophthalmitis after sutureless cataract surgery

BACKGROUND

Sutureless cataract surgery has recently increased in popularity because of the rapid visual rehabilitation and the inherent reduction of surgically induced astigmatism.

METHODS

This procedure is dependent on a lamellar, multiplaned incision. As with new surgical techniques, associated complications become evident with time. Recently, there have been several cases of infectious endophthalmitis after this procedure. The authors report on nine cases of sterile endophthalmitis. In all nine cases, surgery was performed with refrigerated balanced salt solution (BSS) and 100 mg of cefazolin and/or 20 mg of methylprednisolone sodium succinate, given subconjunctivally, at its completion.

RESULTS

All nine cases occurred in a period of time during which 68 cases were performed using refrigerated BSS for irrigation. These nine cases came from two different surgeons using basically the same surgical technique. After the investigation of these complications, the refrigerated BSS was discontinued, and there have been no episodes of sterile endophthalmitis in the last 650 cases.

CONCLUSION

It appears that refrigerated BSS should be avoided if periocular injections are going to be used. It may be that the cold BSS fails to allow sufficient tissue swelling to seal the surgical incision, allowing for subconjunctival injections to seep into the wound, and leading to a sterile endophthalmitis.

The effect of a medical journal club on residents' knowledge of clinical epidemiology and biostatistics

BACKGROUND

We performed a prospective controlled trial of a monthly journal club to determine if it would increase pediatric residents' knowledge of clinical epidemiology and biostatistics.

METHODS

Intervention residents received two didactic sessions before the journal club started. Eight monthly journal club sessions followed. Pediatric residents at another institution served as controls. Intervention and control residents completed a pre- and post-test on clinical epidemiology and biostatistics.

RESULTS

Neither the intervention nor the control group showed a significant change in test scores over the 9-month period.

CONCLUSION

A more intensive and more structured approach is needed to effectively teach clinical epidemiology and biostatistics to residents.

Clinical predictors of bacterial versus aseptic meningitis in childhood

STUDY OBJECTIVE

To assess the reliability of meningeal signs and other physical findings in predicting bacterial and aseptic meningitis at various ages.

DESIGN

Children requiring lumbar puncture were evaluated prospectively for meningeal signs and other physical parameters before lumbar puncture.

SETTING

Emergency department of Children's Hospital of Wisconsin.

PARTICIPANTS

One hundred seventy-two children, aged 1 week to 17 years, with meningitis (53 bacterial and 119 aseptic).

MEASUREMENTS AND MAIN RESULTS

Nuchal rigidity was present in 27% of infants aged 0 to 6 months with bacterial meningitis versus 95% of patients 19 months or older (P = .0001). Three percent of infants 0 to 6 months old with aseptic meningitis had nuchal rigidity versus 79% of patients 19 months or older (P = .0005). Seventy-two percent of infants 12 months of age or younger with bacterial meningitis has at least one positive meningeal sign versus 17% of infants with aseptic meningitis (P = .0001). Eighty-five percent of children older than 12 months with meningitis had at least one positive meningeal sign, 93% with bacterial meningitis, and 82% with aseptic meningitis.

CONCLUSION

Despite a lack of meningeal signs, a high index of suspicion for meningitis is essential when evaluating the febrile infant 12 months of age or younger.

Review of 180 episodes of chest pain in 134 children

This study intends to establish the etiology of chest pain in the pediatric population, to determine the causal relationship between a cardiac problem and chest pain in acutely sick children, and to provide a systematic approach to the management of these patients. The charts of 134 patients, up to 19 years of age, seen in the emergency department (ED) of Children's Hospital of Wisconsin (CHW) with the primary diagnosis of "chest pain" during a five-year period were reviewed. In 15% of these patients, a relationship was established between chest pain and actual cardiac disease. A thorough history and physical examination are the diagnostic "keys" in evaluating pediatric patients with chest pain; laboratory tests are often helpful when indicated by the history and physical examination. In the majority of the cases, reassurance is all that is required; occasionally, pharmacologic treatment is recommended. Hospitalization is rarely necessary.

Delay in obstetrical care in newly diagnosed teenage pregnancy

A retrospective study of 42 adolescent patients diagnosed as being pregnant between June 1987 and February 1990 at the Downtown Health Center (DHC), an inner city pediatric primary care clinic, was conducted to determine whether patients referred to a hospital-based Teen Pregnancy Clinic (TPC) were seen within a reasonable period of time. The frequency of sexually transmitted diseases (STDs) was also determined when these women were initially seen at TPC. Only 5 of the 42 patients seen at DHC had a pelvic exam prior to referral. Of the 40 patients seen at TPC, 20% were not seen until four weeks or more after initial diagnosis. Fifty percent had a STD. Pediatricians should recognize that pregnant teenagers may have a significant delay between diagnosis of pregnancy and entry into obstetrical care. Pelvic exam including cultures for STDs is recommended prior to referral.

Cyanoacrylate temporary tarsorrhaphy in the management of corneal epithelial defects

Cyanoacrylate tarsorrhaphy is an easily administered, painless technique for the temporary management of corneal epithelial defects. We have used the technique in 17 patients to treat persistent epithelial defects and exposure keratitis, as well as following epikeratophakia, allowing the tarsorrhaphy to remain in place for 1 to 15 days (mean, 5.7 days). Eleven of the 17 patients required only one application of cyanoacrylate; five had additional cyanoacrylate applied at the time of the original tarsorrhaphy to produce more extensive lid closure; and one required additional cyanoacrylate on day 3 to produce more extensive lid apposition.

Stereopsis testing to reduce overreferral in preschool vision screening

Three- and 4-year-old children who obtain the minimum failing visual acuity result of one-line difference between eyes in preschool vision screening with isolated optotypes have a high rate of overreferral. We evaluated the Random Dot E Stereotest (RDES) to determine if a passing result at a high threshold on this test, as administered by lay screeners, could safely nullify referral for a minimum failing visual acuity test result. Fifty-eight children with a "one-line difference" result also had the RDES administered to them during screening at distances of 40 cm and 1.5 m. Upon subsequent ophthalmologic examination, 45 of these children were found to be normal, and 13 had abnormal findings. Thirty-nine of the children with normal examinations had correctly passed the RDES at 1.5 m. Seven of the 13 children with abnormal findings had correctly failed the RDES. Thus, the specificity of stereotesting was 87% and the sensitivity was 54%. Among the six children who falsely passed the stereopsis test during screening, best-corrected visual acuity was no worse than 20/40 and no child had greater than a one-line difference in acuity. Therefore, no amblyopia was missed. If a passing result on the stereotest at 1.5 m had been allowed to nullify a one-line difference referral, overreferral would have decreased 87% but underreferral would have increased 46%. We cannot yet recommend modifying current visual acuity referral criteria based on stereopsis testing results until the sensitivity of stereopsis screening by lay screeners at a sufficient threshold is improved.

Increasing rubella seronegativity despite a compulsory school law

To determine if lower rubella susceptibility persisted five to seven years after immunization legislation, we retrospectively reviewed the serologic status of 341 outpatients from 1985 to 1987 in an inner-city school age population. Seronegative rates increased significantly during the two-year study period from 4.2 to 24.5 percent (17 percent overall). (Beta = 6.8%, 95% CI = 3.3, 10.3). Charts were reviewed for 57 of 58 seronegative and 114 seropositive controls. Estimates were then made to the population of 341 subjects. Those with documented rubella immunization had a seronegative rate of 13 percent compared to 19 percent if the immunization status was unknown. For patients who received care in our clinic for less than two years, 32 percent were seronegative compared to 10 percent for those treated greater than or equal to 2 years (odds ratio = 0.31, 95% CI = 0.16, 0.60). Among patients immunized in 1977 or 1978, 33 percent were seronegative compared to 7 percent immunized at other times (OR = 0.21, 95% CI = 0.07, 0.63). Factors associated with increased rubella seronegativity include immunization in 1977 or 1978 and lack of continuity of care in our clinic. Much of the increase remains unexplained.

Medulloblastoma cell line secretes platelet-derived growth factor

Medulloblastoma is the most common malignant childhood brain tumor in which aggressive growth produces recurrence in approximately 50% of appropriately treated cases and metastases along the neuraxis in 30%. To date, no studies exist concerning the production of autocrine growth factors by this brain tumor type. Malignant brain tumors in adults often produce platelet-derived growth factor (PDGF). A medulloblastoma cell line, TE-671, has been used for many years in pediatric neuro-oncologic studies. We assayed this medulloblastoma cell line for the production of PDGF. PDGF is produced by medulloblastoma cells grown in monolayer tissue culture and stimulates PDGF-sensitive 3T3 fibroblasts to incorporate tritiated thymidine in a dose-dependent fashion. This biologic activity is blocked by PDGF antibodies in a dose-dependent relationship. We postulate that PDGF produced by medulloblastoma cells plays a role in the growth of this tumor by stimulating mitogenic activity.