Penicillin Prophylaxis in Children with Sickle Cell Disease

Children who have sickle cell disease and are under the age of five years are at increased risk of life-threatening pneumococcal infection due to absent or non-functional spleens and a decreased immune response. To prevent pneumococcal infection, the American Academy of Pediatrics recommends the use of penicillin prophylaxis in children with sickle cell disease under the age of five and in older children who have had a previous severe pneumococcal infection or have functional/surgical asplenia. These recommendations are based on two landmark studies, the first evaluating the effectiveness of penicillin prophylaxis and the second evaluating the duration of prophylaxis. Although the mortality rate from infection has been reduced following penicillin prophylaxis, altered immunologic response and penicillin-resistant S. pneumoniae remain a concern. This paper will review the literature that supports the use of penicillin prophylaxis, potential problems associated with prolonged therapy and recommendations for prophylaxis.

Environment and Obesity in the National Children's Study

We describe the approach taken by the National Children's Study (NCS) to understanding the role of environmental factors in the development of obesity. We review the literature with regard to the two core hypotheses in the NCS that relate to environmental origins of obesity and describe strategies that will be used to test each hypothesis. Although it is clear that obesity in an individual results from an imbalance between energy intake and expenditure, control of the obesity epidemic will require understanding of factors in the modern built environment and chemical exposures that may have the capacity to disrupt the link between energy intake and expenditure. Through its embrace of the life-course approach to epidemiology, the NCS will be able to study the origins of obesity from preconception through late adolescence, including factors ranging from genetic inheritance to individual behaviors to the social, built, and natural environment and chemical exposures. It will have sufficient statistical power to examine interactions among these multiple influences, including geneenvironment and geneobesity interactions. A major secondary benefit will derive from the banking of specimens for future analysis.

A novel plain abdominal radiograph sign to diagnose malrotation with volvulus

Malrotation with associated volvulus is a potentially lethal event for a neonate. The gold standard for diagnosis is an upper gastrointestinal contrast study. However this can delay the diagnosis and the timing of surgical intervention. We present a novel abdominal radiographic sign; duodenal and gastric dilatation occurring in association with limited small bowel gas confined to the right lower quadrant of abdomen and the total absence of colonic air that is indicative of malrotation with associated volvulus. This allows for an earlier diagnosis and expeditious surgery.

Development of a vaccine to prevent Japanese encephalitis: a brief review

Japanese encephalitis (ICD 10: A83.0) is an important specific viral encephalitis caused by the Japanese encephalitis virus, a virus of the Flavivirus group. Millions of people, especially those in endemic areas of developing countries in Asia, are at high risk from this infection. Therefore proper management to deal with this virus is essential. There is no specific treatment for Japanese encephalitis virus. Supportive and symptomatic treatments are usually used, which emphasize the importance of prevention in this specific neurological disorder. Vector control or vaccination can be used to prevent the disease. Because the existing Japanese encephalitis vaccine poses some undesirable problems, a new vaccine is needed. The process of developing a new vaccine is briefly discussed.

Lymphoma in adolescents and young adults

Non-Hodgkin (NHL) and Hodgkin (HL) lymphomas are represented prominently in the adolescent and young adult (AYA) population. These diseases represent 11% of total cancer diagnoses in children, 4% in those 40 years of age and older, and 13% in AYA (aged 15-39 years). Although age-adjusted incidence rates of NHL increase with age, the more aggressive lymphomas are seen more commonly in the younger population with a transition to low-grade, indolent subtypes as the population ages. Burkitt lymphoma, diffuse large B-cell lymphoma, lymphoblastic lymphoma, and anaplastic large cell lymphoma make up the most common subtypes in the AYA population, although within the subgroup age 30-39 years, follicular lymphoma becomes more prominent. As a result, much of the armamentarium in the treatment of aggressive NHL and HL in adults is based on data from pediatric clinical trials. There are obvious limitations to this approach. It is vital that we gain a more thorough understanding of the biology and therapeutic responsiveness of NHL and HL in the AYA population. Thus, we must leverage the large prospective and retrospective trials that have been completed to date and redirect our approaches to cancer care in this unique population. We review the epidemiological data on NHL and HL from the Surveillance, Epidemiology and End Results registries as a cornerstone for a comparative analysis of therapeutic outcomes available in this population.

Relative lack of conditional survival improvement in young adults with cancer

Cancer prognosis is usually reported in terms of survival from time of diagnosis. For patients surviving a period of time after diagnosis, conditional survival (CS) accounts for changing risk over time. This report provides information on how CS in cancer patients changes as a function of age at diagnosis. Using data from the US Surveillance, Epidemiology and End Results database, we examined survival for patients diagnosed between 1973 and 2002. The average annual percent change (AAPC) in CS during the first 5 years after diagnosis was evaluated for the 14 most common cancers occurring in young adults, defined as 15- to 39-year-olds, and how they compared with cancers that are more common in older and younger patients. For all cancers, young adult patients had less CS improvement over time than younger or older patients, and this difference was most pronounced in those aged 20 to 29 years (45% below the mean). Eleven of the 14 most common cancers in 15- to 39-year-olds either had a lower CS improvement after diagnosis than either younger or older patients, or than just the older patients. Young adults with leukemia had the greatest improvement in CS over time. In conclusion, young adults with cancer have not enjoyed the same improvement in CS over time compared with other age groups. Explanations for this deficit include the biologic nature of the type of cancers in young adults and less effective therapies for patients in the age group. Regardless of the reasons, the deficit is yet another challenge faced by young adult patients that merits further study.

Psychosocial outcomes and service use among young adults with cancer

At the crossroads between pediatric and older adult groups, young adults with cancer may be underserved or inadequately or inappropriately served by existing support services. Empirical evidence has not established well the extent to which utilization of psychosocial support services delivered throughout a continuum of care results in desired outcomes. If self-efficacy is demonstrated to play a significant role in promoting quality of life and psychological well-being in young adult cancer patients, then a cancer-specific self-efficacy model can serve as an evidence-based framework for developing, implementing, and testing new interventions. A focus on self-efficacy has the potential to promote young adults' abilities to remain active and independent, seek and understand medical information, manage stress, cope with treatment-related side effects, maintain a "positive attitude," regulate emotions, and seek social support. Future research should aim to identify which patients represent at-risk targets for intervention, as well as the most appropriate time points along the continuum of care at which patients/survivors are most likely to benefit from delivery/utilization of psychosocial support services.

Prenatal di(2-ethylhexyl)phthalate exposure and length of gestation among an inner-city cohort

OBJECTIVE

Our objective was to assess the relationship between di(2-ethylhexyl)phthalate (DEHP) exposure during pregnancy and gestational age at delivery among 311 African American or Dominican women from New York City.

METHODS

Forty-eight-hour personal air and/or spot urine samples were collected during the third trimester. DEHP levels were measured in air samples and 4 DEHP metabolite levels were measured in urine. Specific gravity was used to adjust for urinary dilution. Gestational age was abstracted from newborn medical records (n = 289) or calculated from the expected date of delivery (n = 42). Multivariate linear regression models controlled for potential confounders.

RESULTS

DEHP was detected in 100% of personal air samples (geometric mean: 0.20 microg/m(3) [95% confidence interval [CI]: 0.18-0.21 microg/m(3)]); natural logarithms of air concentrations were inversely but not significantly associated with gestational age. Two or more of the DEHP metabolites were detected in 100% of urine samples (geometric mean: 4.8-38.9 ng/mL [95% CI: 4.1-44.3 ng/mL]). Controlling for potential confounders, gestational age was shorter by 1.1 days (95% CI: 0.2-1.8 days) for each 1-logarithmic unit increase in specific gravity-adjusted mono(2-ethylhexyl)phthalate concentrations (P = .01) and averaged 5.0 days (95% CI: 2.1-8.0 days) less among subjects with the highest versus lowest quartile concentrations (P = .001). Results were similar and statistically significant for the other DEHP metabolites.

CONCLUSIONS

Prenatal DEHP exposure was associated with shorter gestation but, given inconsistencies with previous findings for other study populations, results should be interpreted with caution, and additional research is warranted.

Plasmacytoid dendritic cells and the control of herpesvirus infections

Type-I interferons (IFN-I) are cytokines essential for vertebrate antiviral defense, including against herpesviruses. IFN-I have potent direct antiviral activities and also mediate a multiplicity of immunoregulatory functions, which can either promote or dampen antiviral adaptive immune responses. Plasmacytoid dendritic cells (pDCs) are the professional producers of IFN-I in response to many viruses, including all of the herpesviruses tested. There is strong evidence that pDCs could play a major role in the initial orchestration of both innate and adaptive antiviral immune responses. Depending on their activation pattern, pDC responses may be either protective or detrimental to the host. Here, we summarize and discuss current knowledge regarding pDC implication in the physiopathology of mouse and human herpesvirus infections, and we discuss how pDC functions could be manipulated in immunotherapeutic settings to promote health over disease.

Vitamin D deficiency, eosinophilic esophagitis, and health literacy

PURPOSE OF REVIEW

To review the recent literature on three topics that are important in pediatric office practice: vitamin D deficiency, eosinophilic esophagitis, and health literacy. Review of current literature will help pediatricians understand the prevalence of vitamin D deficiency, its potential negative health effects, and vitamin D supplementation guidelines. This article also provides practitioners with current knowledge of the evaluation and treatment of eosinophilic esophagitis. The article concludes with a summary of recent literature on health literacy and available techniques to improve patient education.

RECENT FINDINGS

Vitamin D deficiency in pediatric and adolescent patients is extremely common and has potential negative skeletal and extra-skeletal effects. Eosinophilic esophagitis is an increasingly recognized problem. Pediatric patients benefit from early recognition and treatment of the disease. There are effective techniques that improve patient health literacy.

SUMMARY

Vitamin D deficiency, eosinophilic esophagitis, and poor health literacy are three important problems that potentially negatively impact the lives of children and adolescents. Pediatricians should regularly counsel their patients regarding appropriate vitamin D intake. Practitioners should be aware of the clinical presentation of eosinophilic esophagitis. Pediatricians should utilize strategies to improve patient education with the goal of improving health outcomes.

Behavioral and mental health challenges for indigenous youth: research and clinical perspectives for primary care

After first discussing historical, community and epidemiologic perspectives pertaining to mental health problems of Indigenous youth and families, this article reviews available research data on behavioral and mental health interventions and the roles that Native and Indigenous research programs are serving. Given the legacy of transgenerational trauma experienced by Indigenous peoples, community-based research and treatment methods are essential for solving these problems. The primary care provider stands in a unique position within the community to offer a "coinvestigator spirit" to youth and families in the pursuit of improving behavioral health. Strategies are presented for using the research literature, and collaborating with communities and families to help solve behavioral and mental health problems.

Pediatric acupuncture: a review of clinical research

Practiced in China for more than 2000 years, acupuncture has recently gained increased attention in the United States as an alternative treatment approach for a variety of medical conditions. Despite its growing prevalence and anecdotal reports of success among pediatric populations, few empirically based studies have assessed the efficacy of acupuncture for children and adolescents. This article presents a review of the current literature, including a systematic appraisal of the methodological value of each study and a discussion of potential benefits and adverse effects of acupuncture. While acupuncture holds great promise as a treatment modality for diverse pediatric conditions, a significant amount of additional research is necessary to establish an empirical basis for the incorporation of acupuncture into standard care.

Endocrine late effects in survivors of pediatric brain tumors

Central nervous system tumors are the most common solid tumor diagnosed in children under the age of 14 years. Chronic health conditions related to endocrine and metabolic late effects are one of the most common medical late effects seen in childhood cancer survivors. Over the past 2 decades, outcomes have improved significantly for children diagnosed with a brain tumor. Curative therapy for childhood brain tumors survivors places them at significant risk for complex multi-organ medical late effects.These late effects can create a negative effect on cognition, growth, organ function, body image, sexual function and quality of life. Treatment related complications can occur many years after completion of therapy. Close monitoring is necessary so that early detection and intervention can hopefully decrease the full negative impact of many of these effects. Lifelong medical surveillance with a multidisciplinary team approach is essential to maximize health and improve the quality of life of survivors of pediatric brain tumors.

Hemifacial lipomatosis, a possible subtype of partial hemifacial hyperplasia: CT and MR imaging findings

We present a case of hemifacial hyperplasia in an infant manifesting predominantly as lipomatosis and hemihypertrophy of the maxilla. To our knowledge, there is only 1 other case report in the literature demonstrating the MR imaging features of this condition. Our case was manifest almost exclusively as lipomatosis, largely lacking muscular hypertrophy/hyperplasia.

Experimental mild traumatic brain injury induces functional alteration of the developing hippocampus

It is estimated that approximately 1.5 million Americans suffer a traumatic brain injury (TBI) every year, of which approximately 80% are considered mild injuries. Because symptoms caused by mild TBI last less than half an hour by definition and apparently resolve without treatment, the study of mild TBI is often neglected resulting in a significant knowledge gap for this wide-spread problem. In this work, we studied functional (electrophysiological) alterations of the neonatal/juvenile hippocampus after experimental mild TBI. Our previous work reported significant cell death after in vitro injury >10% biaxial deformation. Here we report that biaxial deformation as low as 5% affected neuronal function during the first week after in vitro mild injury of hippocampal slice cultures. These results suggest that even very mild mechanical events may lead to a quantifiable neuronal network dysfunction. Furthermore, our results highlight that safe limits of mechanical deformation or tolerance criteria may be specific to a particular outcome measure and that neuronal function is a more sensitive measure of injury than cell death. In addition, the age of the tissue at injury was found to be an important factor affecting posttraumatic deficits in electrophysiological function, indicating a relationship between developmental status and vulnerability to mild injury. Our findings suggest that mild pediatric TBI could result in functional deficits that are more serious than currently appreciated.

Reflux related hospital admissions after fundoplication in children with neurological impairment: retrospective cohort study

OBJECTIVE

To examine the impact of fundoplication on reflux related hospital admissions for children with neurological impairment.

DESIGN

Retrospective, observational cohort study. Setting 42 children's hospitals in the United States.

PARTICIPANTS

3721 children with neurological impairment born between 2000 and 2005 who had at least one hospital admission at a study hospital before their fundoplication.

INTERVENTION

Fundoplication.

MAIN OUTCOME MEASURES

Incident rate ratio for reflux related hospital admissions, defined as the post-fundoplication admission rate divided by the pre-fundoplication admission rate.

RESULTS

Of the 955 285 children born during the study period, 144,749 (15%) had neurological impairment. Of these, 27,720 (19%) were diagnosed as having gastro-oesophageal reflux disease, of whom 6716 (24%) had a fundoplication. Of these, 3721 (55%) had at least one previous hospital admission and were included in the study cohort. After fundoplication, hospital admissions decreased for any reflux related cause (incident rate ratio 0.69, 95% confidence interval 0.67 to 0.72; P<0.01), aspiration pneumonia (0.71, 0.62 to 0.81; P<0.01), gastro-oesophageal reflux disease (0.60, 0.57 to 0.63; P<0.01), and mechanical ventilation (0.40, 0.37 to 0.43; P<0.01), after adjustment for other patient and hospital related factors that may influence reflux related hospital admissions. Hospital admissions increased for asthma (incident rate ratio 1.52, 1.38 to 1.67; P<0.01) and remained constant for pneumonia (1.07, 0.98 to 1.17; P=0.16). Conclusions Children with neurological impairment who have fundoplication had reduced short term reflux related hospital admissions for aspiration pneumonia, gastro-oesophageal reflux disease, and mechanical ventilation. However, admissions for pneumonia remained constant and those for asthma increased after fundoplication. Comparative effectiveness data for other treatments (such as gastrojejunal feeding tubes) are unknown.

Oral rotavirus vaccines: how well will they work where they are needed most?

Rotavirus vaccines hold promise to decrease the burden of severe diarrhea in the poorest countries, where 85% of deaths due to rotavirus occur. However, the potency of live oral vaccines is lower in these challenging settings than in middle- and upper-income countries. Many hypotheses have been suggested to explain these differences that could provide clues to improve the ultimate success of these novel vaccines. Although introduction today of even moderately effective vaccines will decrease the morbidity and mortality associated with rotavirus in low-income settings, research is urgently needed to understand why these differences in efficacy occur and what could be done to improve vaccine performance to maximize the life-saving benefits of vaccination.

Mental health and emergency medicine: a research agenda

The burden of mental illness is profound and growing. Coupled with large gaps in extant psychiatric services, this mental health burden has often forced emergency departments (EDs) to become the de facto primary and acute care provider of mental health care in the United States. An expanded emergency medical and mental health research agenda is required to meet the need for improved education, screening, surveillance, and ED-initiated interventions for mental health problems. As an increasing fraction of undiagnosed and untreated psychiatric patients passes through the revolving doors of U.S. EDs, the opportunities for improving the art and science of acute mental health care have never been greater. These opportunities span macroepidemiologic surveillance research to intervention studies with individual patients. Feasible screening, intervention, and referral programs for mental health patients presenting to general EDs are needed. Additional research is needed to improve the quality of care, including the attitudes, abilities, interests, and virtues of ED providers. Research that optimizes provider education and training can help academic settings validate psychosocial issues as core components and responsibilities of emergency medicine. Transdisciplinary research with federal partners and investigators in neuropsychiatry and related fields can improve the mechanistic understanding of acute mental health problems. To have lasting impact, however, advances in ED mental health care must be translated into real-world policies and sustainable program enhancements to assure the uptake of best practices for ED screening, treatment, and management of mental disorders and psychosocial problems.

Does assessing sleep inadequacy across its continuum inform associations with child and family health?

INTRODUCTION

The purpose of this study was to examine the prevalence and characteristics of children experiencing a continuum of inadequate sleep and its associations with child, family, and environmental variables.

METHOD

A secondary analysis of weighted responses of 68,418 parents or caregivers of children aged 6 to 17 years participating in the 2003 National Survey of Children's Health was conducted. Inadequate sleep was categorized as mild, moderate, or severe.

RESULTS

Approximately one third of parents reported their child's sleep inadequacy as mild (18.6%), moderate (6.8%), or severe (5.8%). Age (P < .001), fair/poor health status (P < .001), frequent depressive symptoms (P < .001), and high parental stress (P < .001) demonstrated a progressive relationship from adequate to severe inadequate sleep. Controlling for child, family, and environment variables, parents of children with inadequate sleep were more likely to report frequent child depressive symptoms, high parental stress, and violent family conflict style.

DISCUSSION

Sleep inadequacy affects 15 million American children, 6 million at a moderate or severe level. Identification of inadequate sleep should prompt further assessment of its associated factors-depressive symptoms, parental stress, and family conflict-for targeted clinical intervention.

Echocardiographic abnormalities in familial dysautonomia

Sudden death accounts for up to 43% of all deaths in patients with familial dysautonomia (FD). The classic features of FD, namely, autonomic dysfunction, high blood pressure, and blood pressure labiality, are all risk factors for cardiac remodeling and hypertrophy. Myocardial remodeling and hypertrophy are independent risk factors for arrhythmias, cardiovascular events, and sudden death. An extensive review of the medical literature found no documentation of structural heart defects or myocardial remodeling in patients with FD. Sixteen patients with FD underwent physical examination, in-clinic blood pressure measurements, and echocardiographic study. On the basis of the findings, the patients were categorized by left ventricular geometric pattern. Twenty-four-hour ambulatory blood pressure monitoring was recommended to all participants. The majority of FD patients were found to have very high blood pressure values both during in-clinic measurements and during ambulatory blood pressure monitoring. Echocardiographic abnormalities were found in 43.75% of the study group; 18.75% of the study group had concentric hypertrophy, among which severe hypertrophy was found in 2 patients. Unknown previously, cardiac remodeling or hypertrophy is common in FD. We recommend that routine cardiac echocardiography be performed in this population, and attempts to treat high blood pressure should begin earlier in life.

Health literacy and child health outcomes: a systematic review of the literature

OBJECTIVES

To review the relationship between parent and child literacy and child health outcomes and interventions designed to improve child health outcomes for children or parents with low literacy skills.

METHODS

We searched Medline and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) for articles published from 1980 through 2008 and included studies that reported original data, measured literacy and >or=1 health outcome, and assessed the relationship between literacy and health outcomes. Health outcomes included health knowledge, health behaviors, use of health care resources, intermediate markers of disease status, and measures of morbidity. Two abstractors reviewed each study for inclusion. Included studies were abstracted into evidence tables and were assessed by using an 11-item quality scale.

RESULTS

We reviewed 4182 new titles and abstracts published since 2003. Fifty-eight articles were retained for full review, and 13 met the inclusion criteria. Eleven articles from the systematic review from 1980 to 2003 met the inclusion criteria, giving us a total of 24 articles. Children with low literacy generally had worse health behaviors. Parents with low literacy had less health knowledge and had behaviors that were less advantageous for their children's health compared with parents with higher literacy. Children whose parents had low literacy often had worse health outcomes, but we found mixed results for the relationship of literacy to the use of health care services. Interventions found that improving written materials can increase health knowledge, and combining good written materials with brief counseling can improve behaviors including adherence. The average quality of the studies was fair to good.

CONCLUSIONS

Child and parent literacy seems associated with important health outcomes. Future research can help us understand under what circumstances this relationship is causal, how literacy and health outcomes are related in noncausal pathways, the relative importance of parent and child literacy, and what interventions effectively reduce health literacy-related disparities.

The health literacy of parents in the United States: a nationally representative study

OBJECTIVE

To assess the health literacy of US parents and explore the role of health literacy in mediating child health disparities.

METHODS

A cross-sectional study was performed for a nationally representative sample of US parents from the 2003 National Assessment of Adult Literacy. Parent performance on 13 child health-related tasks was assessed by simple weighted analyses. Logistic regression analyses were performed to describe factors associated with low parent health literacy and to explore the relationship between health literacy and self-reported child health insurance status, difficulty understanding over-the-counter medication labeling, and use of food labels.

RESULTS

More than 6100 parents made up the sample (representing 72600098 US parents); 28.7% of the parents had below-basic/basic health literacy, 68.4% were unable to enter names and birth dates correctly on a health insurance form, 65.9% were unable to calculate the annual cost of a health insurance policy on the basis of family size, and 46.4% were unable to perform at least 1 of 2 medication-related tasks. Parents with below-basic health literacy were more likely to have a child without health insurance in their household (adjusted odds ratio: 2.4 [95% confidence interval: 1.1-4.9]) compared with parents with proficient health literacy. Parents with below-basic health literacy had 3.4 times the odds (95% confidence interval: 1.6-7.4) of reporting difficulty understanding over-the-counter medication labels. Parent health literacy was associated with nutrition label use in unadjusted analyses but did not retain significance in multivariate analyses. Health literacy accounted for some of the effect of education, racial/ethnic, immigrant-status, linguistic, and income-related disparities.

CONCLUSIONS

A large proportion of US parents have limited health-literacy skills. Decreasing literacy demands on parents, including simplification of health insurance and other medical forms, as well as medication and food labels, is needed to decrease health care access barriers for children and allow for informed parent decision-making. Addressing low parent health literacy may ameliorate existing child health disparities.

Performance of serology assays for diagnosing celiac disease in a clinical setting

Diagnosis of celiac disease frequently depends upon serology assays. We set out to prospectively assess the diagnostic value of five serology tests: an enzyme-linked immunosorbent assay (ELISA) for tissue transglutaminase (tTG)-immunoglobulin A (IgA) and tTG-IgG, a chemiluminescence assay for tTG-IgA, an ELISA for deamidated gliadin peptide (DGP) IgG and IgA screening, and detection of endomysial antibodies (Abs) by indirect immunofluorescence. One hundred sixteen children at high risk for developing celiac disease were evaluated clinically and underwent small bowel biopsies and blood serology tests. We examined differences between younger and older children in terms of clinical presentation, test performance, and the ability of high Ab levels to correctly predict diagnosis of celiac disease. Celiac disease was diagnosed for 85 (73%) children. No significant clinical differences were observed between the biopsy-positive and biopsy-negative groups. Children < or = 3 years of age revealed higher concentrations of tTG-IgA and DGP Abs than children >3 years old (P = 0.017 and 0.007, respectively). High Ab concentrations were predictive of villous atrophies, with sensitivities ranging from 92.8% to 97.9%, depending on the assay and the cutoff points applied. Sensitivities, specificities, positive predictive values, and negative predictive values varied among assays and improved after correction for best cutoff points. Assay specificities obtained in the clinical setting were lower than expected. The new tTG-IgA chemiluminescence assay demonstrated high throughput but low specificity (74.2%). The tTG-IgA ELISA exhibited the highest test efficiency, and the tTG-IgA chemiluminescence assay was suitable for large-scale screening, with reduced specificity. High concentrations of celiac disease-specific Abs bring into question the need for performance of biopsies on children at high risk.

Celiac disease: presentation of 109 children

PURPOSE

The clinical features of patients with celiac disease (CD) are variable. In the present study, clinical and laboratory features of 109 patients with CD were retrospectively evaluated.

MATERIALS AND METHODS

In all cases, diagnosis of CD was made by European Society for Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) criteria and clinical and laboratory findings, including hematological and biochemical analyses, immunoglobulin levels, autoantibodies [antinucler antibody (ANA), antidouble stranded DNA (dsDNA), antimitochondrial antibody (AMA), anti-smooth muscle antibody (ASMA), liver kidney antibody (LKM-1), anti thyroid peroxidase (TPO), anti thyroglobulin (Tg)], bone mineral density (BMD), and electroencephalogram were evaluated. The type of CD was recorded.

RESULTS

Of 109 patients with CD, 66 (60.6%) were classical type, 41 (37.6%) were atypical type and 2 (1.8%) were silent type. The mean age was 8.81 +/- 4.63 years and the most common symptom was diarrhea (53.2%) followed by failure to thrive, short stature, and abdominal pain. Paleness (40.4%), underweight (34.8%), and short stature (31.2%) were the most common findings. Iron deficinecy anemia (81.6%), zinc deficiency (64.1%), prolonged prothrombin time (35.8%), and elevated transaminase levels (24.7%) were the most common laboratory findings. Eight percent of patients had at least 1 autoantibody, and 28 of 52 patients had low BMD. Four of 38 patients had abnormalty in electroencephalograms. The prevalance of selective immunoglobulin (Ig) A deficiency was 9.1%. Histocompatibility antigen HLA-DQ and/or DQ8 genotypes were found in 91% of patients. Abdominal distention, iron deficiency, prolonged prothrombine time, hypoalbuminemia, and elevated transaminase levels were more significantly frequent in the classical type than atypical type (p < 0.005).

CONCLUSION

Although classical CD was seen in most patients in the present study, clinical variability of the condition should be kept in mind.

Common medical comorbidities associated with cerebral palsy

The medical issues associated with the diagnosis of cerebral palsy (CP) can have significant interplay with the neuromuscular issues that most physiatrists manage in the clinical setting. Identification and appropriate management of these common comorbidities by the primary care and subspecialist physicians can have significant impact on the quality of life of the patient and family. Some of these issues are prevalent across all gross motor function classification system (GMFCS) levels of severity, whereas others more commonly complicate the care of those children with the more severe GMFCS levels IV and V. Performance of a complete review of systems to address the potentially complex medical comorbidities and subsequent application of appropriate screening tools can assist in achieving optimal outcomes in children with CP and their families.

Family support services in pediatric palliative care

A fundamental premise of pediatric palliative care is that support is provided not only to the ill child but to the family as well. In doing so, a number of services may be offered to family members throughout the child's illness, at the time of death and into bereavement, such as respite, counseling, expressive therapies, and bereavement support. Support may also be needed for the child's peers at school, church, or on sporting teams. Evidence on family supportive care in pediatric palliative care research is scarce. The majority of existing studies are undertaken with bereaved parents. Although these studies are insightful, further information is needed to understand families' needs along the illness trajectory and to determine whether unmet needs exist.

Maternal literacy and associations between education and the cognitive home environment in low-income families

OBJECTIVE

To determine whether maternal literacy level accounts for associations between educational level and the cognitive home environment in low-income families.

DESIGN

Analysis of 369 mother-infant dyads participating in a long-term study related to early child development.

SETTING

Urban public hospital.

PARTICIPANTS

Low-income mothers of 6-month-old infants.

MAIN EXPOSURE

Maternal literacy level was assessed using the Woodcock-Johnson III/Bateria III Woodcock-Munoz Tests of Achievement, Letter-Word Identification Test. Maternal educational level was assessed by determining the last grade that had been completed by the mother.

MAIN OUTCOME MEASURE

The cognitive home environment (provision of learning materials, verbal responsivity, teaching, and shared reading) was assessed using StimQ, an office-based interview measure.

RESULTS

In unadjusted analyses, a maternal literacy level of ninth grade or higher was associated with increases in scores for the overall StimQ and each of 4 subscales, whereas a maternal educational level of ninth grade or higher was associated with increases in scores for the overall StimQ and 3 of 4 subscales. In simultaneous multiple linear regression models including both literacy and educational levels, literacy continued to be associated with scores for the overall StimQ (adjusted mean difference, 3.7; 95% confidence interval, 1.7-5.7) and all subscales except teaching, whereas maternal educational level was no longer significantly associated with scores for the StimQ (1.8; 0.5-4.0) or any of its subscales.

CONCLUSIONS

Literacy level may be a more specific indicator of risk than educational level in low-income families. Studies of low-income families should include direct measures of literacy. Pediatricians should develop strategies to identify mothers with low literacy levels and promote parenting behaviors to foster cognitive development in these at-risk families.

Large-scale adeno-associated viral vector production using a herpesvirus-based system enables manufacturing for clinical studies

The ability of recombinant adeno-associated viral (rAAV) vectors to exhibit minimal immunogenicity and little to no toxicity or inflammation while eliciting robust, multiyear gene expression in vivo are only a few of the salient features that make them ideally suited for many gene therapy applications. A major hurdle for the use of rAAV in sizeable research and clinical applications is the lack of efficient and versatile large-scale production systems. Continued progression toward flexible, scalable production techniques is a prerequisite to support human clinical evaluation of these novel biotherapeutics. This review examines the current state of large-scale production methods that employ the herpes simplex virus type 1 (HSV) platform to produce rAAV vectors for gene delivery. Improvements have substantially advanced the HSV/AAV hybrid method for large-scale rAAV manufacture, facilitating the generation of highly potent, clinical-grade purity rAAV vector stocks. At least one human clinical trial employing rAAV generated via rHSV helper-assisted replication is poised to commence, highlighting the advances and relevance of this production method.

Congenital cytomegalovirus (CMV) epidemiology and awareness

This commentary highlights and discusses the implications of a number of recent studies that refine epidemiologic knowledge of CMV infection and assess awareness of congenital CMV among clinicians and the public. These studies highlight that: (1) congenital CMV results in a disease burden that is substantial and severe; (2) a high proportion of United States women of reproductive age are susceptible to CMV infection; (3) the majority of congenital CMV infections in the United States result from recurrent infections among pregnant women; (4) CMV seroprevalence and seroincidence are much higher among racial/ethnic minorities and persons of lower socioeconomic status (SES); (5) household transmission of CMV appears to be an important transmission route in the United States; (6) sexual transmission of CMV appears to be an important transmission route in some population sub-groups in the United States; (7) women have limited awareness and knowledge about congenital CMV; (8) most obstetrician/gynecologists do not counsel women about prevention of congenital CMV; (9) most women view CMV prevention messages positively.

Proposal for Staging Airway Hemangiomas

OBJECTIVE: To describe a method of airway infantile hemangioma staging using standardized assessment of airway narrowing, and hemangioma location and volume, as determined with endoscopy and CT angiography.

STUDY DESIGN: Case series with chart review.

SETTING: Tertiary pediatric hospital, 2003-2008.

SUBJECTS AND METHODS: Subjects included airway hemangioma patients evaluated at a tertiary pediatric hospital. Data collected were age at first symptoms, diagnostic evaluation, percent airway compromise, and estimated hemangioma volume. Data were analyzed with descriptive and Fisher exact statistics.

RESULTS: Twelve patients were identified and seven had complete data sets. Mean age at first symptoms was 1.9 months (SD 1.09 months, range 0.5-4 months). Evaluation consisted of nasopharyngoscopy, microlaryngoscopy, CT angiography, and/or MRI. Mean laryngeal airway narrowing was estimated at 63.75 percent (SD 19.0%, range 40%-90%). Total hemangioma volume was less in patients with isolated (focal) endolaryngeal hemangiomas compared with airway hemangiomas associated with extralaryngeal (segmental) hemangiomas. Airway hemangioma stages were stage one (5 of 12; 41.6%), stage two (6 of 12; 50.0%), and stage three (1 of 12; 8.3%).

CONCLUSION: This method of airway hemangioma staging may be applicable to treatment planning and used to measure treatment outcomes.

Treatment with high-dose proton pump inhibitors helps distinguish eosinophilic esophagitis from noneosinophilic esophagitis

BACKGROUND

Eosinophilic esophagitis (EE) is a clinical entity that is recognized increasingly in children. The treatment of EE has been debated since its identification as a clinical entity separate from reflux esophagitis. We hypothesize that the treatment with a high-dose proton pump inhibitor (HDPPI) helps differentiate EE from noneosinophilic esophagitis (NEE).

PATIENTS AND METHODS

Retrospective review of 2221 patients who underwent esophagogastroduodenoscopy (EGD) with biopsies was undertaken. Sixty-nine patients had more than or equal to 15 eosinophils/high-power field (eos/HPF) in 1 or more esophageal levels. Of those, 36 were initially treated with HDPPI for 3 months followed by repeat EGD. Patients who demonstrated histologic response were classified as NEE. Patients with no histologic response were diagnosed as having EE and treated with HDPPI+swallowed fluticasone for 3 months followed by repeat EGD.

RESULTS

Of the 36 patients, histologic response was seen in 14 (39%) after treatment with HDPPI; 95% confidence interval (0.23-0.54). Swallowed fluticasone was added to the treatment of the 22 patients who did not show histologic response to HDPPI alone. Of those, 15 patients underwent repeat endoscopies. Seven patients were lost to follow-up or did not have repeated EGDs. Histologic response was observed in 9 of 15 (60%) patients. Of the nonresponders (6 of 15), 5 of 6 (83%) self-reported noncompliance with the swallowed fluticasone. Patients with more than or equal to 15 eos/HPF at all 3 levels (25 of 36) were less likely to respond to HDPPI alone and more likely to be categorized as EE (18 of 25), P=or<0.043. Symptomatically, 28 of 36 patients reported resolution of symptoms after HDPPI therapy alone, P=or<0.0001, regardless of histology. Visual endoscopic findings during the first and second EGDs did not show any significance in differentiating EE from NEE, P=0.625 and P=0.2405, respectively.

CONCLUSIONS

The study demonstrates that HDPPI can be used to help differentiate EE from NEE histologically. Moreover, patients with more than or equal to 15 eos/HPF at all 3 levels are less likely to respond to HDPPI than patients with more than or equal to 15 eos/HPF at fewer than 3 levels. Therefore, having more than or equal to 15 eos/HPF at 1 or 2 biopsy levels does not necessarily establish the diagnosis of EE. Symptomatic response to HDPPI does not correlate with histologic findings. Clinical management guided by EGD with biopsy helps distinguish patients with EE from those with NEE.

Disparities in access to pediatric neurooncological surgery in the United States

OBJECTIVE

The objective of this study was to investigate whether disparities in access to high-volume centers for neurooncological care existed in the United States in 1988-2005.

METHODS

A retrospective analysis of the Nationwide Inpatient Sample (1988-2005) was performed, with additional factors incorporated from the Area Resource File (2006). International Classification of Diseases, Ninth Revision, diagnosis/procedure coding was used to identify patients. High-volume centers were defined as those with > or =50 neurosurgical cases per year. Patients >18 years of age were excluded. Covariates included age, gender, race, Charlson Index score, insurance, and county-level characteristics (including median home value, proportion of foreign born residents, and county neurosurgeon density). Multivariate analysis was performed by using multiple logistic regression models. P values of <.05 were considered statistically significant.

RESULTS

A total of 4421 patients were identified; 1651 (37.34%) were admitted to high-volume centers. Overall access to high-volume centers improved slightly over the 18-year period (odds ratio [OR]: 1.04). Factors associated with greater access to high-volume centers included greater county neurosurgeon density (OR: 1.72) and greater county home value (OR: 1.66). Factors associated with worse access included Hispanic ethnicity (OR: 0.68) and each 1% increase in foreign residents per county (OR: 0.59). All reported P values were <.05.

CONCLUSION

This study demonstrates that racial and socioeconomic disparities in access to high-volume neurooncological care exist for the pediatric population. We also identify numerous prehospital factors that potentially contribute to persistent disparities and may be amenable to change through national health policy interventions.

A systematic review and meta-analysis of childhood leukemia and parental occupational pesticide exposure

OBJECTIVES

We conducted a systematic review and meta-analysis of childhood leukemia and parental occupational pesticide exposure.

DATA SOURCES

Searches of MEDLINE (1950-2009) and other electronic databases yielded 31 included studies.

DATA EXTRACTION

Two authors independently abstracted data and assessed the quality of each study.

DATA SYNTHESIS

Random effects models were used to obtain summary odds ratios (ORs) and 95% confidence intervals (CIs). There was no overall association between childhood leukemia and any paternal occupational pesticide exposure (OR = 1.09; 95% CI, 0.88-1.34); there were slightly elevated risks in subgroups of studies with low total-quality scores (OR = 1.39; 95% CI, 0.99-1.95), ill-defined exposure time windows (OR = 1.36; 95% CI, 1.00-1.85), and exposure information collected after offspring leukemia diagnosis (OR = 1.34; 95% CI, 1.05-1.70). Childhood leukemia was associated with prenatal maternal occupational pesticide exposure (OR = 2.09; 95% CI, 1.51-2.88); this association was slightly stronger for studies with high exposure-measurement-quality scores (OR = 2.45; 95% CI, 1.68-3.58), higher confounder control scores (OR = 2.38; 95% CI, 1.56-3.62), and farm-related exposures (OR = 2.44; 95% CI, 1.53-3.89). Childhood leukemia risk was also elevated for prenatal maternal occupational exposure to insecticides (OR = 2.72; 95% CI, 1.47-5.04) and herbicides (OR = 3.62; 95% CI, 1.28-10.3).

CONCLUSIONS

Childhood leukemia was associated with prenatal maternal occupational pesticide exposure in analyses of all studies combined and in several subgroups. Associations with paternal occupational pesticide exposure were weaker and less consistent. Research needs include improved pesticide exposure indices, continued follow-up of existing cohorts, genetic susceptibility assessment, and basic research on childhood leukemia initiation and progression.

Suicide in adolescents: a worldwide preventable tragedy

The tragedy of suicide in adolescents is experienced by all countries of the world with as many as 200,000 youth and young adults ending their life in the prime of their life because of self-murder each year. Such a tragedy should be unacceptable to clinicians of the world and this article examines factors leading to such death in our youth with recommendations on how to prevent such a worldwide carnage. A major issue in suicide prevention is to screen all children and adolescents for depression and other factors that may trigger suicide in adolescence.

Phthalates and other additives in plastics: human exposure and associated health outcomes

Concern exists over whether additives in plastics to which most people are exposed, such as phthalates, bisphenol A or polybrominated diphenyl ethers, may cause harm to human health by altering endocrine function or through other biological mechanisms. Human data are limited compared with the large body of experimental evidence documenting reproductive or developmental toxicity in relation to these compounds. Here, we discuss the current state of human evidence, as well as future research trends and needs. Because exposure assessment is often a major weakness in epidemiological studies, and in utero exposures to reproductive or developmental toxicants are important, we also provide original data on maternal exposure to phthalates during and after pregnancy (n = 242). Phthalate metabolite concentrations in urine showed weak correlations between pre- and post-natal samples, though the strength of the relationship increased when duration between the two samples decreased. Phthalate metabolite levels also tended to be higher in post-natal samples. In conclusion, there is a great need for more human studies of adverse health effects associated with plastic additives. Recent advances in the measurement of exposure biomarkers hold much promise in improving the epidemiological data, but their utility must be understood to facilitate appropriate study design.

A novel immunoregulatory protein in human colostrum, syntenin-1, for promoting the development of IgA-producing cells from cord blood B cells

Human colostrum contains many bioactive factors that must promote the development of intestinal mucosal immunity in infants. Especially, the presence of certain cytokines such as transforming growth factor (TGF)-beta or IL-10 has been of great interest for IgA production as a function of mucosal immune response. In the present study, we attempted to investigate whether unidentified factors inducing generation of IgA-producing cells from naive B cells might exist in colostrum. For this purpose, colostrum samples were directly added to a culture consisting of naive B cells and dendritic cells from cord blood and CD40 ligand-transfected L cells, comparing with recombinant IL-10 (rIL-10) and/or rTGF-beta. It was noted that most colostrum samples alone were able to induce IgA-secreting cells at higher levels than rIL-10 and/or rTGF-beta. IgA-inducing activity of colostrum was abolished by neither anti-neutralizing mAbs against IL-10 nor TGF-beta, though partially by anti-IL-6 mAb. We prepared partially purified fractions from both pooled colostrums with and without IgA-inducing activity and comparatively performed quantitative proteomic analysis by two-dimensional difference gel electrophoresis followed by liquid chromatography-mass spectrometry. As a result, syntenin-1 was identified as a candidate for IgA-inducing protein in colostrum. Western blot analysis indicated that levels of syntenin-1 in colostrum samples were correlated with their IgA-inducing activities. Moreover, we demonstrated that recombinant syntenin-1 could induce preferentially IgA production from naive B cells. These results suggest that syntenin-1 serves as one of IgA-inducing factors for B cells.

Revisiting practice-based research networks as a platform for mental health services research

Practice-based research networks (PBRNs)-collaborations of practice settings that work together to generate research knowledge-are underused in mental health services research. This article proposes an agenda for mental health services research that uses a variety of PBRN structures and that focuses on what really happens in practice, the effectiveness of practice innovations in real world care, the challenges of implementing evidence supported interventions, modification of clinician behavior, and assessment of the effect of mental health policy changes on practice. The challenges of conducting research within PBRNs are substantial, including difficulties in maintaining positive member relations, securing ongoing funding, sustaining productivity, overcoming IRB entanglements and achieving both scientific excellence in recruitment and measurement validity and utility for practitioner members. However, the awareness of these challenges allows researchers and practitioners to build networks that creatively overcome them and that infuse mental health services research with heavy doses of the realities of everyday clinical practice.

Positive association between Helicobacter pylori and gastroesophageal reflux disease in children

OBJECTIVES

The role of Helicobacter pylori (H pylori) in gastroesophageal reflux disease (GERD) remains controversial, particularly in children, because there are limited published data. Adult studies suggested that H pylori infection may protect against GERD by causing atrophic gastritis, which leads to reduced gastric acid secretion. The objective of our study was to determine the role of H pylori infection in the development of GERD in a pediatric population.

PATIENTS AND METHODS

A retrospective analysis of 420 patients (M:F = 214:206) who underwent esophagogastroduodenoscopy (EGD) with biopsies between January 2000 and April 2006 was conducted. Patient demographics, clinical indications for EGD and the prevalence of reflux esophagitis (RE), the biomarker for GERD, in 2 groups, H pylori positive and H pylori negative, were reviewed. The prevalence of RE in the H pylori-positive and H pylori-negative groups was further analyzed on the basis of sex and age (<1 year, 1-10 years, >10 years). The mean age of the study population was 8.2 years (range 0-20 years). The clinical indications for EGD were as follows: recurrent abdominal pain (n = 186, 44%), malabsorption (n = 80, 19%), persistent vomiting (n = 80, 19%), suspected eosinophilic gastrointestinal disorders (n = 63, 15%), and others such as upper gastrointestinal bleeding or inflammatory bowel disease surveillance (n = 11, 3%). Statistical analysis was performed by using chi test, Fisher exact test, and multivariate logistical regression analysis.

RESULTS

Among the 420 patients, 16 patients (3.8%) were positive for H pylori and 167 patients (39.8%) were found to have RE. Thirteen patients with H pylori were found to have histologic evidence of RE. The prevalence of RE in the H pylori-positive population was 81.3% compared with 38.1% in the H pylori-negative population (P < or = 0.05). There were no patients with H pylori in the youngest age group. In the second age group (1-10 years), 100% of the H pylori-positive patients had RE, whereas 44.6% of the H pylori-negative patients had RE (P < or = 0.05). Both male and female patients with H pylori had a higher prevalence of RE, 77.8% and 85.7%, respectively. On a multivariate logistical regression, for the overall study cohort, H pylori-positive patients had an odds ratio of 5.79 of developing RE compared with H pylori-negative patients (P < or = 0.05).

CONCLUSIONS

Our study results indicate that there is a significantly higher prevalence of RE in an H pylori-infected cohort independent of age or sex. The findings suggest that H pylori infection in children is positively associated with RE.

Differential cytotoxic effects of mono-(2-ethylhexyl) phthalate on blastomere-derived embryonic stem cells and differentiating neurons

Potential applications of embryonic stem (ES) cells are not limited to regenerative medicine but can also include in vitro screening of various toxicants. In this study, we established mouse ES cell lines from isolated blastomeres of two-cell stage embryos and examined their potential use as an in vitro system for the study of developmental toxicity. Two ES cell lines were established from 69 blastomere-derived blastocysts (2.9%). The blastomere-derived ES (bm-ES) cells were treated with mono-(2-ethylhexyl) phthalate (MEHP) in an undifferentiated state or after directed differentiation into early neural cell types. We observed significantly decreased cell viability when undifferentiated bm-ES cells were exposed to a high dose of MEHP (1000 microM). The cytotoxic effects of MEHP were accompanied by increased DNA fragmentation, nuclear condensation, and activation of Caspase-3, which are biochemical and morphological features of apoptosis. Compared to undifferentiated bm-ES cells, considerably lower doses of MEHP (50 and 100 microM) were sufficient to induce cell death in early neurons differentiated from bm-ES cells. At the lower doses, the number of neural cells positive for the active form of Caspase-3 was greater than that for undifferentiated bm-ES cells. Thus, our data indicate that differentiating neurons are more sensitive to MEHP than undifferentiated ES cells, and that undifferentiated ES cells may have more efficient defense systems against cytotoxic stresses. These findings might contribute to the development of a new predictive screening method for assessment of hazards for developmental toxicity.