Use of supplemental vitamin d among infants breastfed for prolonged periods

OBJECTIVES

To determine the rate of vitamin D supplementation in predominantly breastfed children. To identify patient characteristics, parental beliefs, and practitioner policies associated with supplementation.

METHODS

A prospective observational study was conducted in a practice-based research network. Network pediatricians completed a survey regarding their policy on vitamin D supplementation for breastfed infants. Parents of children 6 to 24 months old completed a survey on the initial type of feeding given to the child, length of breastfeeding, formula supplementation, and use of multivitamins. Parents indicated their level of agreement with statements regarding vitamin D supplementation.

RESULTS

Among 44 responding pediatricians, 36.4% indicated that they recommended vitamin D supplementation for all breastfed infants. A total of 2364 surveys were completed on age-eligible children; 1140 infants were breastfed for at least 6 months with little or no formula supplementation. The rate of vitamin D use for these infants was 15.9%. Use of vitamin D was significantly associated with parental agreement that their child's pediatrician recommended supplementation (odds ratio [OR]: 7.8), and that vitamins are unnecessary because breast milk has all needed nutrition (OR: 0.12). Among parents of predominantly breastfed infants who indicated that their child's doctor recommended vitamin D, 44.6% gave the supplementation to their child. Conversely, 67% of parents agreed that breast milk has all needed nutrition, and only 3% of these parents gave vitamin D to their children.

CONCLUSIONS

A minority of breastfed infants received vitamin D supplementation. Educational efforts directed at both physicians and parents are needed to increase compliance with vitamin D supplementation guidelines.

Development of a symptom score for clinical studies to identify children with a documented viral upper respiratory tract infection

The objective of this study was to develop a symptom scoring system for use in clinical studies that differentiates children with cold symptoms who have an identifiable viral etiology for their upper respiratory tract infection (URI) from those in whom no virus is detected. Nasal swabs for PCR testing for identification of respiratory viruses were obtained on children aged 2-11 y at baseline and when parents thought their child was developing a cold. Parental-recorded severity of specific symptoms in children with and without a documented viral URI were compared. Nasal swabs were obtained on 108 children whose parents reported their child was developing a cold. A viral etiology was identified in 62 of 108 (57.4%) samples. Symptom measures that best differentiated children with a viral etiology from those without were significant runny nose and significant cough on days 1-4 of the illness. A URI symptom score was developed based on these symptoms, with a sensitivity of 81.4%, specificity of 61.9%, and accuracy of 73.3%. Parental impression is only a moderately accurate predictor of viral URI in children. Our URI symptom score provided a more accurate method for identifying children with viral URIs for clinical studies.

The in vivo gastrointestinal activity of TD-5108, a selective 5-HT(4) receptor agonist with high intrinsic activity

The in vivo preclinical pharmacodynamic profile of TD-5108, a selective 5-HT(4) receptor agonist with high intrinsic activity, was compared to that of the clinically studied gastrointestinal pro-kinetic agents, tegaserod, cisapride and mosapride. The activity of TD-5108 was evaluated in guinea pig colonic transit, rat oesophageal relaxation and dog gastrointestinal smooth muscle contractility models. Subcutaneous administration of TD-5108, tegaserod, cisapride and mosapride increased guinea pig colonic transit (rank order of potencies: TD-5108 > tegaserod > cisapride > mosapride). Following intravenous and intraduodenal dosing, TD-5108, tegaserod, cisapride and mosapride produced dose-dependent relaxation of the rat oesophagus. On a molar basis, TD-5108 was approximately twofold less potent than tegaserod following intravenous dosing but 6- or 86-fold more potent than cisapride or mosapride, respectively, and 9- or 18-fold more potent than tegaserod or cisapride, respectively, after intraduodenal administration. Orally dosed TD-5108 increased the contractility of the canine antrum, duodenum and jejunum with higher potency than tegaserod. The selective 5-HT(4) receptor agonist, TD-5108, demonstrates robust in vivo activity in the guinea pig, rat and dog gastrointestinal tracts.

How should immunization rates be measured in the office setting? A study from PROS and NMA PedsNet

The aim of the study was to compare the validity and reliability of 2 sampling methods for measuring immunization rates to a reference standard in a national sample of pediatric office practices. The consecutive method involved patients seen consecutively in the office for any reason; the random record was a random selection of medical records; and the reference standard active method, data of a randomly selected subgroup of children in the random record survey were supplemented with information from a telephone interview. The consecutive method of assessing immunization rates results in rates that are, on average, higher and closer to the reference standard, but also more variable. The random record method rates are lower and further from the study reference standard compared with the consecutive method, but more precise. The consecutive method for measuring practice immunization rates could be a useful quality improvement tool as practices seek to improve immunization delivery and quality of care. It is inexpensive, simple, and easy to implement.

Nanonails: a simple geometrical approach to electrically tunable superlyophobic surfaces

In this work, dynamically tunable, superlyophobic surfaces capable of undergoing a transition from profound superlyophobic behavior to almost complete wetting have been demonstrated for the first time. In the initial state, with no voltage applied, these surfaces exhibit contact angles as high as 150 degrees for a wide variety of liquids with surface tensions ranging from 21.8 mN/m (ethanol) to 72.0 mN/m (water). Upon application of an electrical voltage, a transition from the superlyophobic state to wetting is observed. We have examined experimentally and theoretically the nature of these transitions. The reported results provide novel methods of manipulating liquids on the microscale.

Medication administration variances before and after implementation of computerized physician order entry in a neonatal intensive care unit

OBJECTIVE

The goal was to determine whether implementation of a computerized physician order entry system was associated with a decrease in medication administration variances in a NICU.

METHODS

A prospective observational study was conducted. Research nurses recorded details of medication administrations for patients in a NICU during standardized observation periods. Details of each administration were compared with the medication order; a variance was defined as a discrepancy between the order and the medication administration. Rates of variances before and after implementation of computerized physician order entry in the NICU were compared. Specific types of and reasons for variances were also compared.

RESULTS

Data on 526 medication administrations, including 254 during the pre-computerized physician order entry period and 272 after implementation of computerized physician order entry, were collected. Medication variances were detected for 19.8% of administrations during the pre-computerized physician order entry period, compared with 11.6% with computerized physician order entry (rate ratio: 0.53). Overall, administration mistakes, prescribing problems, and pharmacy problems accounted for 74% of medication variances; there were no statistically significant differences in rates for any of these specific reasons before versus after introduction of computerized physician order entry. Administration of a medication at the wrong time accounted for 53.1% of all variances. Variance rates related to giving a drug at the wrong time were significantly lower in the computerized physician order entry period than in the pre-computerized physician order entry period (rates: 6.7% and 9.9%, respectively; rate ratio: 0.53).

CONCLUSIONS

Implementation of computerized physician order entry in a NICU was associated with a significant decrease in the rate of medication administration variances. However, even with the use of computerized physician order entry, variances were noted for >11% of all medication administrations, which suggests that additional methods may be needed to improve neonatal patient safety.

Evaluation of an anonymous system to report medical errors in pediatric inpatients

OBJECTIVE

To compare reports of medical errors in hospitalized children submitted using an electronic, anonymous reporting system with those submitted via traditional incident reports.

STUDY DESIGN

During the 3-month study period in 2003, reports of medical errors from 2 units at a large children's hospital were made using an electronic, anonymous system. Three reviewers independently evaluated each report and determined whether the events described constituted a medical error. An identical procedure was used to categorize medical error data collected via incident reports from the 2 study units from 1999 to 2002.

RESULTS

A total of 146 reports were made using the anonymous system, 131 of which documented medical errors. The rate of reporting medical errors with the anonymous system was 2.41/100 patient-days. The rate of reporting medical errors via incident reports in 1999-2002 was 2.40/100 patient-days. However, 33.8% of all incident reports dealt with mislabeled laboratory specimens; after excluding these reports, the rate of medical errors documented via incident reports was 1.56/100 patient-days. The rate of reporting was significantly higher with the anonymous system (rate ratio 1.54, 95% confidence interval 1.26, 1.90). With the anonymous system, 25.2% of reported medical errors were near-misses compared with 12.6% of the errors reported with the incident report system (P = .001).

CONCLUSIONS

Implementation of the anonymous reporting system with training was associated with a statistically significant increase in the rate of reported medical errors. The reporting of near-miss events was significantly increased, suggesting this may be a useful format for gathering data on this type of medical error.

Frequency and characteristics of pediatric and adolescent visits in naturopathic medical practice

OBJECTIVES

This work sought to identify naturopathic physicians in Washington State who frequently provide pediatric care and to describe the conditions treated and therapies recommended for children.

PATIENTS AND METHODS

A mailed survey of licensed naturopathic physicians residing in Washington State collected demographic information and practice descriptions. For naturopathic physicians treating > or = 5 pediatric patients per week, data were collected on the conditions seen and treatments provided to children during a 2-week period.

RESULTS

Of 499 surveys delivered to providers, 251 surveys were returned (response rate: 50.3%). Among the 204 naturopathic physicians currently practicing, only 31 (15%) saw > or = 5 children per week. For these pediatric naturopathic physicians, pediatric visits constituted 28% of their office practice. Pediatric naturopathic physicians were more likely to be licensed midwives (19.4% vs 0.6%) and treated significantly more patients per week (41.6 vs 20.2) than naturopathic physicians who provided less pediatric care. Eighteen of the 31 pediatric naturopathic physicians returned data on 354 pediatric visits; 30.5% of the visits were by children < 2 years old, and 58.5% were by those < 6 years old. The most common purpose for presentation included health supervision visits (27.4%), infectious disease (20.6%), and mental health conditions (12.7%). Pediatric naturopathic physicians provided immunizations during 18.6% of health supervision visits by children < 2 years old and 27.3% of visits by children between the ages of 2 and 5 years.

CONCLUSIONS

Although most naturopathic physicians in Washington treat few children, a group of naturopathic physicians provide pediatric care as a substantial part of their practice. Based on the ages of children seen and the conditions treated, pediatric naturopathic physicians may provide the majority of care for some children. Efforts should be made to enhance collaboration between naturopathic physicians and conventional providers so that optimal care can be provided to children.

Steroid control of gonadotropin-releasing hormone secretion: associated changes in pro-opiomelanocortin and preproenkephalin messenger RNA expression in the ovine hypothalamus

The endogenous opioid peptides have been implicated in mediating the actions of estrogen and progesterone on GnRH release. We used in situ hybridization histochemistry to determine whether steroid-induced changes in GnRH/LH release in the female sheep are associated with changes in the cellular mRNA content of the precursors for beta-endorphin (pro-opiomelanocortin; POMC) and met-enkephalin (pre-proenkephalin; PENK). Two specific hypotheses were tested. First, that the inhibitory actions of progesterone are associated with an increase in opioid gene expression in specific hypothalamic nuclei. Our data support this hypothesis. Thus, an increase in progesterone was associated with increased POMC gene expression in the arcuate nucleus and PENK in the paraventricular nucleus. Further, the increase in POMC was restricted to regions of the arcuate nucleus that contain steroid sensitive beta-endorphin neurons. Our second hypothesis, that gene expression for the two opioid precursors would decrease prior to the start of the estradiol-stimulated GnRH surge, was not supported. Rather, POMC (but not PENK) gene expression in the arcuate nucleus was significantly higher in estradiol-treated animals than controls at the peak of the GnRH surge. These data suggest that beta-endorphin neurons in subdivisions of the arcuate nucleus and enkephalin neurons in the paraventricular nucleus are part of the neural network by which progesterone inhibits LH release. While enkephalin neurons may not play a role in estrogen positive feedback, increases in POMC mRNA in the arcuate nucleus at the time of the GnRH peak may be important for replenishing beta-endorphin stores and terminating estrous behavior.

Oral outpatient chemotherapy medication errors in children with acute lymphoblastic leukemia

BACKGROUND

Although medication errors are 1 of the most common types of medical errors, their frequency in pediatric patients receiving oral outpatient chemotherapeutic agents is unknown. The prescribing, dispensing, and parental administration of these medications to children receiving treatment for acute lymphoblastic leukemia (ALL) were systematically reviewed to determine the rate and types of medication errors occurring in these patients.

METHODS

During a 2-month study period, parents of children with ALL were contacted and asked to participate in the study before a regularly scheduled clinic appointment. At the visit, the parent demonstrated how each medication was administered. A pediatric oncologist reviewed the medical record to determine the correct treatment regimen for study patients. After comparing the correct treatment regimen with what was administered, a classification of "no medication error," "medication error," or "cannot determine" due to insufficient information was made for each indicated drug. Identified medication errors were subclassified as prescribing, dispensing, or administration errors.

RESULTS

Data on 172 chemotherapeutic medications for 69 patients were analyzed. One or more errors occurred with 17 of the 172 (9.9%) medications; a classification of "cannot determine" was made for 12 (7.0%) medications. Among the 17 medication errors there were 12 (7.0%) administration errors and 5 (2.9%) prescribing errors. There were no pharmacy dispensing errors. All errors were due to incorrect dosing or failure to administer an indicated medication. At least 1 medication error occurred in 13 of the 69 (18.8%) study patients.

CONCLUSIONS

Prescribing and administration medication errors occurred with nearly 10% of chemotherapeutic drugs administered to outpatient children with ALL. Systematic changes, including computerized physician order entry and simplification of treatment protocols, should be considered.

Echinacea purpurea for prevention of upper respiratory tract infections in children

OBJECTIVE

The aim of this study was to determine whether Echinacea purpurea given to children for the treatment of acute upper respiratory tract infection (URI) was effective in reducing the risk of subsequent URI.

DESIGN

This was a secondary analysis of data from a randomized, double-blind, placebo-controlled trial of Echinacea for the treatment of URI in children.

SETTING

The study was conducted as a joint project between the Puget Sound Pediatric Research Network (Seattle, WA) and Bastyr University (Kenmore, WA).

PARTICIPANTS

A total of 524 children ages 2 to 11 years were enrolled in the study.

INTERVENTION

Children were monitored for URIs over a 4-month observation period during the fall/winters of 2000-2001 and 2001-2002. At entry the children were randomized to receive Echinacea or placebo to treat acute URIs during the observation period.

MAIN OUTCOME MEASURES

The occurrence of a second URI and the number of days between the end of the first URI and the start of the second URI was ascertained. Survival and Cox regression analyses were used to determine whether children who took Echinacea for their URIs were less likely to develop subsequent URIs.

RESULTS

Among the 401 children with at least one URI treated with study medication, 69.2% of those receiving placebo developed a second URI versus 55.8% of those who received Echinacea. Use of Echinacea was associated with a 28% decreased risk of subsequent URI (p = 0.01, 95% confidence interval 8%-44% decreased risk).

CONCLUSIONS

Echinacea purpurea may be effective in reducing the occurrence of subsequent URIs in children. However this finding needs to be replicated in a URI prevention trial.

Optical transmission through double-layer metallic subwavelength slit arrays

We present measurements of transmission of infrared radiation through double-layer metallic grating structures. Each metal layer contains an array of subwavelength slits and supports transmission resonance in the absence of the other layer. The two metal layers are fabricated in close proximity to allow coupling of the evanescent field on individual layers. The transmission of the double layer is found to be surprisingly large at particular wavelengths, even when no direct line of sight exists through the structure as a result of the lateral shifts between the two layers. We perform numerical simulations using rigorous coupled wave analysis to explain the strong dependence of the peak transmission on the lateral shift between the metal layers.

Lead Exposure as a Risk Factor for Amyotrophic Lateral Sclerosis

BACKGROUND

The etiology of amyotrophic lateral sclerosis (ALS) likely involves an environmental component. We qualitatively assessed literature on ALS and lead exposure. Problems of study design make case reports and studies of lead in blood or tissues difficult to interpret. Most previous case-control studies found an association of ALS with self-reported occupational exposure to lead, with increased risks of 2- to >4-fold. However, these results may have been affected by recall bias.

OBJECTIVE

To address inconsistencies among published reports, we used both lead biomarkers and interview data to assess lead exposure, and we evaluated the role of genetic susceptibility to lead.

METHODS

We conducted a case-control study in New England in 1993-1996 with 109 ALS cases and 256 population-based controls. We measured blood and bone lead levels, the latter using X-ray fluorescence, and interviewed participants regarding sources of lead exposure.

RESULTS

In our study, ALS was associated with self-reported occupational lead exposure, with a dose response for cumulative days of exposure. ALS was also associated with blood and bone lead levels, with a 1.9-fold increase in risk for each mug/dl increment in blood lead and a 2.3- to 3.6-fold increase for each doubling of bone lead. A polymorphism in the delta-aminolevulinic acid dehydratase gene was associated with a 1.9-fold increase in ALS risk.

CONCLUSION

These results, together with previous studies, suggest that lead exposure plays a role in the etiology of ALS. An increase in mobilization of lead from bone into blood may play a role in the acute onset of disease.

Association between parental satisfaction and antibiotic prescription for children with cough and cold symptoms

BACKGROUND

Providers' interest in satisfying parents may provide an impetus for unnecessary antibiotic use in children.

OBJECTIVES

To determine (1) whether receipt of antibiotics at a visit for cough and cold symptoms was associated with increased satisfaction and (2) whether nonreceipt of antibiotics at an initial visit but subsequent receipt of antibiotics in the course of the same illness episode was associated with decreased satisfaction.

METHODS

Prospective cohort study of patients 2-10 years of age presenting to a university-affiliated pediatric clinic with cough and cold symptoms. Parents were enrolled at the index visit and then followed up by phone at least 7 days later (mean time to follow-up, 14.9 days). Satisfaction with the index visit on a 10 point scale was the primary outcome. The primary predictors were whether antibiotics were prescribed at the index visit and, if not, whether they were prescribed since that visit. Linear and median regression were used to adjust for income, child age, parental race and individual provider.

RESULTS

A total of 539 parents were enrolled in the study, and 378 (70%) completed follow-up interviews. The mean age of participating children was 4.67 years (SD 2.16). Overall 47% of patients received antibiotics at the index visit, and 8% of those that did not reported receiving them between the index visit and the follow-up assessment. In the regression model, receiving antibiotics at the index visit trended toward being associated with higher satisfactions scores (0.28; P = 0.08). Among those who did not receive antibiotics initially, receiving them subsequently was associated with significantly lower median satisfaction score for the index visit (-3.0; P < 0.01).

CONCLUSIONS

Receiving antibiotics after an initial visit for cough and cold symptoms at which antibiotics were not prescribed is associated with decreased satisfaction. Use of contingency prescriptions may be an important intervention.

CAPRI and RASAL impose different modes of information processing on Ras due to contrasting temporal filtering of Ca2+

The versatility of Ca²⁺ as a second messenger lies in the complex manner in which Ca²⁺ signals are generated. How information contained within the Ca²⁺ code is interpreted underlies cell function. Recently, we identified CAPRI and RASAL as related Ca²⁺-triggered Ras GTPase-activating proteins. RASAL tracks agonist-stimulated Ca²⁺ oscillations by repetitively associating with the plasma membrane, yet CAPRI displays a long-lasting Ca²⁺-triggered translocation that is refractory to cytosolic Ca²⁺ oscillations. CAPRI behavior is Ca²⁺- and C2 domain–dependent but sustained recruitment is predominantly Ca²⁺ independent, necessitating integration of Ca²⁺ by the C2 domains with agonist-evoked plasma membrane interaction sites for the pleckstrin homology domain. Using an assay to monitor Ras activity in real time, we correlate the spatial and temporal translocation of CAPRI with the deactivation of H-Ras. CAPRI seems to low-pass filter the Ca²⁺ signal, converting different intensities of stimulation into different durations of Ras activity in contrast to the preservation of Ca²⁺ frequency information by RASAL, suggesting sophisticated modes of Ca²⁺-regulated Ras deactivation.

Effectiveness of a parental educational intervention in reducing antibiotic use in children: a randomized controlled trial

OBJECTIVE

To determine whether an educational intervention aimed at parents leads to fewer antibiotic prescriptions for their children.

DESIGN

Placebo-controlled, randomized controlled trial.

SETTING

Offices of primary care pediatricians who are members of a regional practice-based research network.

PARTICIPANTS

Healthy children younger than 24 months old enrolled at the time of an office visit.

INTERVENTIONS

Parents of study children were randomized to receive either a pamphlet and videotape (featuring one of their child's pediatricians) promoting the judicious use of antibiotics (intervention group) or brochures about injury prevention (control group). A total of 499 eligible children were enrolled, and data on outpatient visits during a 12-month observation period were collected.

MAIN OUTCOME MEASURES

We compared the number of visits for upper respiratory tract infections (URIs), number of diagnoses and antibiotic prescriptions for otitis media and/or sinusitis and total number of antibiotics per patient among children in the intervention and control groups using Poisson regression analysis, adjusted for clustering into different practices.

RESULTS

: Data on 4924 visits were reviewed; 28.8% of these visits were because of URI symptoms. The mean number of visits per study patient for URI symptoms was 2.8. Including all visits, the mean number of diagnoses of otitis media in study children was 2.1, mean number of diagnoses of otitis media and/or sinusitis was 2.3 and mean number of antibiotic prescriptions was 2.4; there were no significant differences between children in the intervention and control groups for any of these outcomes. Overall physicians prescribed 1 or more antibiotics during 45.9% of visits for a chief complaint of URI symptoms; 92% of antibiotic usage in children presenting with URI symptoms was for a diagnosis of otitis media and/or sinusitis.

CONCLUSIONS

An educational intervention aimed at parents did not result in a decrease in the number of antibiotic prescriptions in their children. The use of antibiotics among children with URI symptoms was common; other interventions promoting the judicious use of these medications are needed.