Providing immunizations in a pediatric emergency department: underimmunization rates and parental acceptance

OBJECTIVES

To assess the vaccination status and vaccinate eligible children with age-appropriate antigens.

DESIGN

Intervention.

SETTING

Pediatric emergency department in an urban, public hospital.

PATIENTS

Convenience sample of children, aged birth through 72 months.

INTERVENTIONS

Immunization of eligible children.

MAIN OUTCOME MEASURES

1) Immunization coverage rates in the sample population, 2) Acceptance rates of immunization.

RESULTS

A total of 9321 children were enrolled over a 2-year period. Fifty-nine percent were documented to be underimmunized. Overall, 2514 children received a total of 6482 immunizations. Parents who carried portable immunization cards documenting that their child was underimmunized were almost five times more likely to accept immunization for their child than parents who lacked documentation (71% vs 15%, P < 0.0001). The estimated cost of providing immunizations in the emergency department was $47.15 per child immunized, or $18.56 per immunization given.

CONCLUSIONS

The majority of children with documentation of immunization status were underimmunized. When documentation of underimmunization was available, parents were significantly more likely to accept vaccination. These data suggest that vaccinating children in nontraditional settings is feasible and support the creation of an accessible vaccine registry.

Psychological assessment of patients requesting orthognathic surgery and the relevance of body dysmorphic disorder

The psychological assessment of patients requesting orthognathic treatment is a vital and integral part of the overall assessment procedure. It allows identification of potential problems at an early stage before irreversible decisions have been made. This paper aims to highlight some of the aspects of psychological assessment which are particularly important. It also discusses current concepts in the diagnosis and treatment of those patients suffering from body dysmorphic disorder (BDD). This is the term applied to those individuals with a normal appearance who present requesting treatment because they believe that they have a 'defect'.

The effect of two alternative methods of canine exposure upon subsequent duration of orthodontic treatment

OBJECTIVES

The aim of this study was to compare the effectiveness, in terms of orthodontic treatment duration, of two methods of canine exposure.

DESIGN

This was a retrospective study using patients' records and lateral cephalometric radiographs.

SAMPLE AND METHODS

50 patients were selected, 25 in each group. In all subjects the impaction was categorized as being 'intermediate'. The methods of canine exposure were: (i) simple surgical exposure; (ii) surgical exposure and placement of an orthodontic attachment, followed by flap replacement.

RESULTS

The treatment duration until the canine was in the line of the arch was 17.7 months in the simple exposure group and 19.3 months in the bonded attachment group. The mean treatment duration (from exposure to debond) was 28.8 months for both groups.

CONCLUSIONS

In terms of treatment duration, no significant difference could be demonstrated between the two methods of surgical exposure to palatally impacted canines.

The use of kinesiography to assess mandibular rest positions following corrective orthognathic surgery

This study utilized the kinesiograph to assess the effect of orthognathic surgery on mandibular rest positions in a group of 27 patients exhibiting vertical facial deformities (14 long faced and 13 short faced patients). Two distinct rest positions were confirmed--clinical and physiological. Following surgery to alter the vertical dimensions, the clinical freeway space was found to adapt immediately whereas the physiological rest position partially adapted in the immediate postoperative period and continued to do so over the following year.

Parental perceptions of access to care and quality of care for inner-city children with asthma

The objective of this study was to describe perceptions of asthma care, morbidity, and health service utilization by parents of children with asthma presenting to an inner-city emergency department (ED). A cross-sectional survey was conducted in an urban pediatric ED, with a convenience sample of 466 parents of children receiving asthma treatment during a consecutive 6-week period in late fall 1995. Parents completed a 30-item survey including sociodemographic data, source of primary medical care and asthma care for their child, selected measures of access to care, and medications used by their child in the week prior to the ED visit. Perceived quality of asthma care was measured by six items (summary score = 0-6) reported to have been performed by the child's asthma doctor: discussion of home peak flow monitoring, child-specific triggers, dogs/cats, smoke, postexacerbation calling instructions, and provision of a written asthma management plan. Functional morbidity was measured by nights of poor sleep, days of cough, and school days missed due to asthma in the previous month. Among 325 patients with previously diagnosed asthma, 308 (97%) were reported to have a source of primary medical care. Of these, 126 respondents identified their primary care provider as the child's usual source of asthma care, while 158 identified the ED as the usual source. The groups did not differ by insurance status, ethnicity, or mean age of the child. Thirty-nine percent of children with the same provider for primary and asthma care compared with 15% of children reported to receive their asthma care predominantly in the ED had used inhaled steroids or cromolyn in the week prior to the ED visit (p < .0001). Children with the same provider for primary and asthma care had a higher mean quality score than children receiving asthma care in the ED (3.7 vs. 2.8, p < 0.0001), but there was no relationship between source of asthma care and functional morbidity. The ED remains the usual source of asthma care for many inner-city children. Among parents surveyed in the ED, there was a significant relationship between source of usual asthma care and quality of care, but a relationship between usual source of asthma care and functional morbidity could not be identified.

Stability of mandibular incisor decompensation in orthognathic patients

This retrospective cephalometric study examined the stability of mandibular incisor decompensation following orthognathic treatment. It also studied the relationship between the mandibular incisor-mandibular plane angle (LIMnp) and the maxillary-mandibular planes angle (MMA). Two groups of 22 subjects each underwent either mandibular advancement only or bimaxillary surgery with mandibular setback. Serial radiographs of each subject were digitized. Twenty-seven Class I subjects who were part of the Leighton Growth Study served as the control. The control group showed a significant association between LIMnp and MMA. For the surgical groups, the only significant relationship between LIMnp and MMA was seen in the mandibular advancement group at debond. No definite indicator was found to suggest that the final MMA dictates the amount of mandibular incisor relapse following debond. Only the bimaxillary group showed an association between changes in LIMnp and changes in MMA during the review period.

The influence of orthognathic surgery on occlusal force in patients with vertical facial deformities

This study utilized bite-force measurements to determine the effect of various orthognathic surgery procedures on occlusal force generation in 42 patients with vertical facial deformities. The results showed that orthognathic surgery produced marked alterations in occlusal force levels which continued to occur up to a year after surgery. Measurements indicated that advancement of the mandible may result in weaker force levels, while bimaxillary surgery for the treatment of a "long face" brings the previously weaker bite force to a more "normal" level.

Gorlin's syndrome: main features and recent advances

Gorlin's syndrome embraces a constellation of cranial, maxillofacial and systemic disorders, which may have a serious effect on both the morbidity and mortality of the patients. Recent work has identified that the disorder is caused by a mutation within a tumour suppressor gene.

Dysmorphophobia: recent developments of interest to the maxillofacial surgeon

Recent changes in the classification of psychiatric illnesses have resulted in the term dysmorphophobia being replaced by that of body dysmorphic disorder (BDD). This paper attempts to alert the clinician to the presenting features of the condition and discusses its management, with particular emphasis on the role of surgery and current concepts of pharmacological treatment. A number of case reports are included to illustrate the diversity of this interesting disorder and the difficulties involved in treatment.

Thyrotropin (TSH) receptor antibodies (TSHrAb) can inhibit TSH-mediated cyclic adenosine 3',5'- monophosphate production in thyroid cells by either blocking TSH binding or affecting a step subsequent to TSH binding

In the present study, rabbit antibodies that possess thyroid stimulation-blocking activity were used to investigate potential mechanisms by which TSH receptor antibodies can inhibit thyroid cell function. The antibodies were produced against two synthetic peptides corresponding to amino acids 357-372 (p357) and 367-386 (p367) of the human TSHr (hTSHr). By enzyme-linked immunosorbent assay, both antisera (alpha 357 and alpha 367) had high titers ( > 1:100,000) of IgG against their respective peptides and recombinant extracellular TSHr protein (ETSHr); alpha 357 had a low IgG titer to p367 (1:800), and alpha 367 had a low IgG titer to p357 ( < 1:200). Based on competitive inhibition studies, alpha 357 and alpha 367 displayed similar relative binding affinities for their respective peptides and for recombinant ETSHr. When tested by commercial RRA, alpha 357 did not block (TSH binding inhibition index, -3.7%), whereas alpha 367 blocked TSH binding to TSHr (TSH binding inhibition index, 53.9%). The blocking effect of alpha 367 could be reversed by incubating the antiserum with p367 before assay. When applied alone to FRTL-5 cells, IgG from alpha 357 inhibited [compared to normal rabbit IgG (NRI); P < 0.01] based cAMP production by the cells, whereas IgG from alpha 367 did not. IgG from both alpha 357 and alpha 367, however, were able to inhibit (P < 0.001) TSH-mediated cAMP production by FRTL-5 cells [bovine (b) TSH, 2.5 x 10(-10) M; cAMP (mean +/- SD; picomoles per ml): NRI, 62.5 +/- 6.1; alpha 357, 12.2 +/- 2.4; alpha 367, 36.2 +/- 3.5]. Alpha 357 continued to inhibit (P < 0.05) cAMP production by FRTL-5 cells in 10(-8) M bTSH, whereas alpha 367 no longer inhibited cAMP production at bTSH concentrations above 5 x 10(-10) M. Compared to NRI, both alpha 357 and alpha 367 were also able to inhibit (P < 0.001) Graves' IgG-mediated cAMP production by FRTL-5 cells. When IgG were tested on FRTL-5 cells in the presence of 10(-7) M forskolin, only alpha 357 inhibited (P < 0.001) cAMP production (NRI, 75.1 +/- 4.8; alpha 357, 52.3 +/- 4.5; alpha 367, 77.2 +/- 1.4). To determine whether the inhibitory effect of alpha 357 on forskolin-mediated stimulation was thyroid cell dependent, IgG were tested on Chinese hamster ovary (CHO) cells transfected with the complementary DNA of the hTSHr (CHO-R). Again, alpha 357 inhibited (P < 0.005) cAMP production mediated by forskolin (at 10(-7) M; NRI, 68.7 +/- 4.4; alpha 357, 36.8 +/- 5.7; alpha 367, 64.6 +/- 8.5). alpha 357 did not inhibit forskolin-mediated cAMP production by untransfected CHO cells (CHO-N), indicating that the inhibitory effect of alpha 357 on forskolin stimulation was TSHr dependent. In addition, alpha 357 inhibited (P < 0.01) basal cAMP production by CHO-R cells, but not by CHO-N cells. alpha 367 had no effect on the basal cAMP production in either CHO-R or CHO-N cells. Neither alpha 357 nor alpha 367 inhibited cholera toxin-mediated cAMP production in FRTL-5 cells. In all relevant bioassays, the inhibitory effects of alpha 357 and alpha 367 could be reversed by preincubating the IgG with the respective peptides. From these data, we conclude that 1) alpha 367 binds to the ETSHr and blocks TSH-mediated cAMP production by inhibiting TSH from binding to its receptor; 2) alpha 357 binds to the TSHr and, without blocking TSH binding, inhibits TSH-mediated cAMP production at a step(s) subsequent to ligand binding that affects adenylate cyclase activity; and 3) forskolin-mediated cAMP production by thyroid cells can be inhibited by IgG that bind directly to the TSHr.

Perceptions of outcome following orthognathic surgery

The definition, evaluation and assurance of quality of health care are becoming increasingly important with health care moving into purchaser/provider mode. This questionnaire based study investigated patient satisfaction and changes in their quality of life following joint orthodontic/surgical treatment for the correction of facial deformity. Questionnaires were distributed to 83 pre-operative and a separate group of 100 postoperative patients with data analysis involving comparison of pre- and postoperative mood states and opinions about various aspects of appearance and personality. The results indicated that the majority of respondents were happy with the outcome of treatment. There was significant improvement in appearance, as well as in self-confidence, overall mood states and the ability to mix socially. The majority of respondents felt that the technical aspects of the operation had been well explained but almost a quarter felt that the effects following surgery were badly explained. Pre-operative counselling, therefore, needs to be improved.

Preparation, perceptions, and problems: a long-term follow-up study of orthognathic surgery

Follow-up of patients who have undergone orthognathic surgery is well documented in the literature, usually in the form of questionnaire-based studies or clinical interviews. However, there have been few long-term follow-up investigations. This study aimed to look at the long-term outcomes of such operative procedures. Questionnaires were sent to 68 patients who had undergone joint orthodontic and orthognathic surgery procedures 5 to 16 years previously, after the patients were contacted by telephone to learn the nature of the study. The 49 responses were compared with a previously analyzed preoperative group and a short-term postoperative group (1 to 3 years following surgery) from the same institution. Respondents showed high levels of satisfaction overall, with the majority believing they had made the correct decision to undergo surgery. The main problem areas identified were those concerning presurgical explanations and lack of advice regarding side-effects. This area requires improvement as postsurgical dissatisfaction can be minimized by accurate descriptions of the treatment. A number of respondents reported persistent lip paresthesia and continued limitation of mouth opening. However, the majority of patients commented that these persistent symptoms had no effect on their daily life.

Delusional depression, hyperparathyroidism, and ECT

A woman with delusional depression and unsuspected primary hyperparathyroid disorders responded completely to electroconvulsive therapy (ECT). Hypercalcemia is a complicating factor in the treatment of delusional depression, but there is little evidence that it is causative and the use of ECT should not be delayed. The case adds to the literature confirming the efficacy and safety of ECT with physically ill patients when it may be a life-saving procedure.

Investigation of the active site cysteine residue of rat liver mitochondrial aldehyde dehydrogenase by site-directed mutagenesis

To determine the active site cysteine residue in aldehyde dehydrogenase, we mutated amino acid residues 49, 162, and 302 of recombinantly expressed rat liver mitochondrial (class 2) aldehyde dehydrogenase. The C49A and C162A mutants were fully active tetrameric enzymes, although the C162A mutant was found to be highly unstable. The C302A mutant was also a tetramer and bound coenzyme, but lacked both dehydrogenase and esterase activities. To test for the role of cysteine 302 as a nucleophile, the residue was mutated to a serine, a poor nucleophile. this C302S mutant was active but was a much poorer catalyst, with a kcat/Km value 7 x 10(5) times lower than that of the recombinant native enzyme. Unlike with native enzyme where deacylation is rate limiting, formation of the serine hemiacetal intermediate appeared to be the rate-limiting step. Cysteine 302 is the only strictly conserved cysteine residue among all the available sequences of the aldehyde dehydrogenase superfamily, supporting the role of this residue as the active site nucleophile of aldehyde dehydrogenase.

Metered-dose inhalers with spacers vs nebulizers for pediatric asthma

OBJECTIVE

To determine whether the administration of beta-agonists by metered-dose inhaler (MDI) with a spacer device is as effective as the administration of beta-agonists by nebulizer for the treatment of acute asthma exacerbations in children.

DESIGN

Randomized trial with two arms.

SETTING

Urban pediatric emergency department (ED) in Bronx, NY.

PATIENTS

Convenience sample of 152 children 2 years and older with a history of at least two episodes of wheezing presenting to the ED with an acute asthma exacerbation.

INTERVENTIONS

Patients were randomly assigned to receive standard doses of a beta-agonist (albuterol) by an MDI with spacer or by a nebulizer. Dosing intervals and the use of other medications were determined by the treating physician.

MEASUREMENTS/MAIN RESULTS

Baseline characteristics and asthma history were recorded. Asthma severity score, peak expiratory flow rate in children 5 years or older, and oxygen saturation were determined at presentation and before admission or discharge. The groups did not differ in age, sex, ethnicity, age of onset of asthma, or asthma severity score at presentation. There were no significant differences between the groups in outcomes, including mean changes in respiratory rate, asthma severity score, and peak expiratory flow rate, oxygen saturation, number of treatments given, administration of steroids in the ED, and admission rate. Patients given MDIs with spacers required shorter treatment times in the ED (66 minutes vs 103 minutes, P < .001). Fewer patients in the spacer group had episodes of vomiting in the ED (9% vs 20%, P < .04), and patients in the nebulizer group had a significantly greater mean percent increase in heart rate from baseline to final disposition (15% vs 5%, P < .001).

CONCLUSIONS

These data suggest that MDIs with spacers may be an effective alternative to nebulizers for the treatment of children with acute asthma exacerbations in the ED.

Psychological aspects of orthognathic surgery: a review of the literature

A review of the literature clearly shows that dental and facial disfigurements have significant effects and can be an important social disadvantage. The motivational patterns of patients requesting orthognathic surgery are many and varied, but a desire for improvement in esthetics and alleviation of functional problems are the two most commonly cited reasons. The careful assessment of patients requesting orthognathic surgery is imperative, because the success of surgery may well depend on careful patient selection. Care must be taken with those patients suspected of exhibiting dysmorphophobic tendencies and, if there is any doubt, psychiatric referral should be undertaken. Patient satisfaction following orthognathic surgery has been reported as high overall, as has been the number of patients who have said they would re-elect to have surgery. Many of the studies found that patients had improved self-confidence and social skills after treatment.

Reduction of morbidity in asthmatic children given a spacer device

STUDY OBJECTIVE

To evaluate whether providing a spacer device and a single, brief demonstration regarding its proper use would result in earlier resolution of asthma symptoms, improved school attendance, and decreased frequency of unscheduled medical visits for asthma among children receiving noncontinuous care in an urban emergency department (ED).

DESIGN

Randomized controlled trial.

SETTING

Urban hospital pediatric ED.

PARTICIPANTS

Eighty-four children with the chief complaint of asthma.

INTERVENTION

Children were enrolled in the ED at the time of an asthma attack and randomly assigned to one of two treatment groups. The spacer group received an inhaled beta-agonist at discharge from the ED with a spacer device. The control group received inhaled or oral beta-agonists without a spacer device. Both groups received other medications at the discretion of the evaluating physician who was not the interviewer in any case. A baseline questionnaire was completed and follow-up by telephone was done at 1 week, and 2, 4, and 6 months after enrollment.

MEASUREMENTS AND RESULTS

The spacer group reported significantly earlier resolution of wheezing (0 days vs 2 days, p < 0.01) at the 2- and 4-month follow-up assessments. They reported significantly fewer days of cough after an asthma attack at 2 months (1 day vs 3 days, p < 0.01) and 4 months (0 days vs 3 days, p < 0.01). The spacer group missed significantly fewer days of school following an asthma attack at 2 and 4 months (0 days vs 2 days, p = 0.05). There was no difference between the two groups on any outcome measures at the 1-week and 6-month follow-up assessments.

CONCLUSIONS

Introducing a spacer device to patients in a busy, inner-city pediatric ED is an effective and efficient intervention that improves the functioning of asthmatic children in terms of resolution of cough and wheeze and school absenteeism.

A region on the human thyrotropin receptor which can induce antibodies that inhibit thyrotropin-mediated activation of in vitro thyroid cell function also contains a highly immunogenic epitope

Autoantibodies to the thyrotropin receptor (TSHr) bind to the extracellular domain of the TSHr (ETSHr) and either stimulate or inhibit thyroid cell function and/or growth. In order to investigate the regulation and the specificity of the immune response to the TSHr, our laboratory recently produced recombinant human ETSHr protein by using the baculovirus expression system. In the present study, we used the recombinant ETSHr protein, a panel of overlapping synthetic peptides derived from the TSHr, and polyclonal rabbit antibodies produced against recombinant ETSHr and synthetic peptides to define a highly immunogenic region (aa 352-388) of the TSHr. Moreover, we used competitive inhibition studies to identify a dominant epitope (aa 367-372) within this region to which ETSHr antibodies react. This immunodominant epitope lies within a region unique to the TSHr when compared to the other glycoprotein hormone receptors. These data, together with the earlier observation that antibodies against aa region 357-372 can inhibit thyrotropin (TSH)-mediated activation of thyroid cells in culture, show that aa 367-372 represents, an immunodominant epitope within a functionally important region which is unique to the TSHr. Therefore, this region may play an important role in the induction or modulation of the specific immune response against the TSHr.