1990 American Journal of Diseases of Children
doi: 10.1001/archpedi.1990.02150330006001
This article is only available in the PDF format. Download the PDF to view the article, as well as its associated figures and tables.
1990 American Journal of Diseases of Children
doi: 10.1001/archpedi.1990.02150330011002pmid: 2396621
Abstract Sir.—I applaud Alan Bedrick's1 acknowledgment in his editorial in the February 1990 issue of AJDC that 6 months of neonatology in a 3-year pediatric residency is excessive. I also concur with his justification for his specialty's presence in residency training. However, I believe he has omitted several important issues relevant to the title of his editorial. Neonatal nurse practitioners (NNPs) do, in fact, cost a lot more money, but rather than admonishing us to "keep [that] in mind," why not confront the issue head on, indicating that few institutions have found the ability to solve that financial conundrum. The neonatal intensive care unit (ICU) is a great place to learn critical care medicine, and 15 to 20 years ago that and the pediatric ICU were the only places in which it could be learned. Now, however, most large, free-standing children's hospitals are veritable ICUs from top References 1. Bedrick AD. Neonatology in residency curricula: how much is too much? AJDC . 1990;144: 159.
1990 American Journal of Diseases of Children
doi: 10.1001/archpedi.1990.02150330011003
This article is only available in the PDF format. Download the PDF to view the article, as well as its associated figures and tables. Abstract In Reply.—I appreciate Dr Winter's thoughts and concerns regarding my recent editorial on the educational values (and limitations) of pediatric resident rotations in neonatal ICUs. However, my brief communication was not intended to be a comprehensive treatise on the "ills of the NICU"; all important and relevant issues could not be covered. However, several of Dr Winter's points require some clarification. My comments concerning utilization of NNPs was not intended as an admonishment or warning, but to point out that service needs can (and should) be met by health care providers other than residents. Unfortunately, the cost of NNPs must be borne by hospitals (in most cases) as part of the cost of doing business. No doubt, this cost will be passed on to the consumer in the form of higher bills for hospital services. Hospitals must absorb this expense if they and the educational programs they support
1990 American Journal of Diseases of Children
doi: 10.1001/archpedi.1990.02150330012005pmid: 2396622
Abstract Sir.—The nonmedical use of anabolic steroids among high school students is an issue that requires better definition. Terney and McLain1 present data that show that 4.4% of the students in a large Chicago, Ill, high school admit to using anabolic steroids, an incidence that is quite concerning. However, the interpretation of the data is compromised by questions regarding the study design. In my experience, the term anabolic steroid is relatively unfamiliar to many, if not most, school-aged children. None of the survey questions in this study verified that the subjects understand this term, and no mention was made of presurvey education. An unknown percentage of the children will be familiar with the term steroid as used for treatment of asthma, allergies, and other medical conditions and might answer in the affirmative without knowing the meaning of anabolic. Another unknown percentage of the children may have had anabolic References 1. Terney R, McLain LG. The use of anabolic steroids in high school students . AJDC . 1990;144:99-103. 2. Wilson JD. Androgen abuse by athletes . Endocrinol Rev . 1988;9:181-199.Crossref
MORTIMER, EDWARD A.;CHERRY, JAMES D.
1990 American Journal of Diseases of Children
doi: 10.1001/archpedi.1990.02150330012004pmid: 2144398
Abstract Sir.—Hecht's account1 of the ill treatment that agent B received at the hands of the justice system would be difficult to believe except for the fact that many such travesties have occurred and continue to occur. Physicians should have little difficulty in recognizing agent B, an agent that has saved millions of lives worldwide in the past 40 years. Accusations regarding the risks of this agent lack scientific validity, but have resulted in litigation and publicity that have endangered its acceptance by the public, impeded the development of analogous products for other disorders, and wasted millions of dollars. Dr Hecht is correct that the current justice mechanisms in this country, particularly those related to liability for personal injury, are inappropriately constituted for the resolution of these issues. Lay juries cannot be expected to comprehend complex scientific issues, and most judges have difficulty understanding them as well. Indeed, References 1. Dr Mortimer and Dr Cherry have served as consultants to, and have received grant money from, a manufacturer of agent B. 2. Hecht F. Agent B: genetics and litogens . AJDC . 1990;144:157-158. 3. Brahams D. Medicine and the law: does pertussis vaccine cause brain damage? Lancet . 1986;1:1284.Crossref 4. Hobbs N, Perrin JM, Ireys HT. Chronically-Ill Children and Their Families . San Francisco, Calif: Jossey-Bass; 1985. 5. Manuel BM. Professional liability: a no-fault solution . N Engl J Med . 1990;322:627-631.Crossref 6. Relman AS. Changing the malpractice liability system . N Engl J Med . 1990;322:626-627.Crossref
1990 American Journal of Diseases of Children
doi: 10.1001/archpedi.1990.02150330012006
Abstract In Reply.—I thank Dr Lee for his thoughtful comments. He raised several issues related to our study about the use of anabolic steroids in high school students.1 He suggested that students with medical conditions, such as growth disorders, allergies, and asthma may be taking steroids or other similar medications and may be confused by the term anabolic steroids. The number of students taking medication for growth disorders is likely to be extremely small. It also seems reasonable to conclude that those students would be very likely to know they were taking growth hormone and would be unlikely to confuse them with anabolic steroids. While it is estimated that 5% to 10% of children will have signs and symptoms of asthma during childhood,2 the number of adolescents with asthma severe enough to necessitate long-term corticosteroid therapy is extremely small. It again appears likely that this select group would References 1. Terney R, McLain LG. The use of anabolic steroids in high school students . AJDC . 1990;144:99-103. 2. Ellis EF. Asthma . In: Behrman RE, Voughan VC, eds. Nelson Textbook of Pediatrics . Philadelphia, Pa: WB Saunders Co; 1987; 495-501. 3. Budkley WE, Yesalis CE III, Friedl KE, Anderson WA, Streit AL, Wright JE. Estimated prevalence of anabolic steroid use among male high school seniors . JAMA . 1988;260:2441-2445.Crossref 4. Johnson MD, Jay S, Shoup B, Rickert VI. Anabolic steroid use by male adolescents . Pediatrics . 1989;83:921-924.
1990 American Journal of Diseases of Children
doi: 10.1001/archpedi.1990.02150330013007pmid: 2396623
Abstract Sir.—There has been a proliferation of articles in the last 5 years about the incidences of diarrheal illnesses and upper respiratory infections in day-care settings. Those unfamiliar with day care might conclude that these are the only infectious conditions encountered to any extent. Such is not the case. I herein report the incidence of "other" infectious conditions in one day-care center during the course of more than 5 years. Methods.—The day-care center is located in Baltimore, Md, in a refurbished church, and serves middle- to upper-middle-class children. The center has been in operation for 5½ years and currently has an average daily attendance of 70 children, aged 2½ to 6 years. There are five teachers, all of whom have degrees in early childhood education, and five to six assistant teachers/volunteers on site when the center is open. Hours of operation are 7:30 am to 5:30 pm. The enrollees, References 1. Smith T, Wilkinson V, Kaplan E. Group A Streptococcus-associated upper respiratory tract infections in a daycare center . Pediatrics . 1989;83: 380-384. 2. Fleming D, Cochi S, Hightower A, Broome C. Childhood upper respiratory infections: to what degree is incidence affected by day-care attendance? Pediatrics . 1987;79:55-60. 3. Tos M, Poulsen G, Bonch J. Tympanometry in 2-year-old children . ORL J Otorhinolaryngol Relat Spec . 1978;40:77-85.Crossref 4. Strangert K. Otitis media in young children in different types of daycare . Scand J Infect Dis . 1977;9:119-123. 5. Ingvarsson L, Lundgren K, Olofsson B. Epidemiology of acute otitis media in children: a cohort study in an urban population . In: Lim DJ, Bluestone CD, Klein JO, et al, eds. Recent Advances in Otitis Media With Effusion: Proceedings of the Third International Symposium . Philadelphia, Pa: BC Decker; 1984:19-22. 6. Lundgren K, Ingvarsson L, Olofsson B. Epidemiologic aspects in children with recurrent otitis media . In: Lim DJ, Bluestone CD, Klein JO, et al, eds. Recent Advances in Otitis Media With Effusion: Proceedings of the Third International Symposium . Philadelphia, Pa: BC Decker; 1984:22-25.
1990 American Journal of Diseases of Children
doi: 10.1001/archpedi.1990.02150330014008pmid: 2264870
Abstract Sir.—The recent overview of the literature on toxoplasmosis by Koskiniemi and colleagues1 should have been more critical to achieve its purpose. It fails to distinguish between proven techniques and solutions with relatively untried procedures. Concerning the serologic diagnosis, the titers in none of the tests correlate with the severity of disease or infection; this is not a shortcoming of the Sabin-Feldman dye test but of the way some people interpret tests for toxoplasmosis. I also disagree with the statement that routine antibody screening is not diagnostic in children with sequelae of intrauterine infection. At least in the United States, where young children rarely become infected from the environment, intelligently applied tests are usually diagnostic. Two, not one, direct agglutination tests are marketed by Bio-Merieux, Lyons, France. The IgG test is useful for general serologic diagnosis. Not correctly identified was the more important capture test for IgM, which References 1. Koskiniemi M, Lappalainen M, Hedman K. Toxoplasmosis needs evaluation . AJDC . 1989;143:724-728. 2. Burg JL, Grover CM, Pouletty P, Boothroyd JC. Direct and sensitive detection of a pathogenic protozoan, Toxoplasma gondii, by polymerase chain reaction . J Clin Microbiol . 1989;27:1787-1782. 3. Hedman K, Lappalainen M, Seppala I, Makaela O. Recent primary Toxoplasma infection indicated by a low avidity of specific IgG . J Infect Dis . 1989;159:736-740.Crossref 4. Decoster A, Darcy F, Caron A, Capron A. IgA antibodies against p30 as markers of congenital and acute toxoplasmosis . Lancet . 1988;2:1104-1107.Crossref 5. Conley FK, Jenkins KA, Remington JS. Toxoplasma gondii infection of the central nervous system: use of the peroxidase-antiperoxidase method to demonstrate Toxoplasma in formalin-fixed, paraffin-embedded tissue sections . Hum Pathol . 1981;12:690-698.Crossref 6. Couvreur J, Desmonts G, Tournier G, Szusterkac M. Study of a homogeneous series of 210 cases of congenital toxoplasmosis in infants aged 0 to 11 months detected prospectively . Ann Pediatr (Paris) . 1984;31:815-819. 7. Wilson CB, Remington JS, Stagno S, Reynolds DW. Development of adverse sequelae in children born with subclinical congenital Toxoplasma infection . Pediatrics . 1980;66:767-774. 8. Fletcher RH, Fletcher SW, Wagner EH. Diagnosis . In: Clinical Epidemiology: The Essentials . 2nd ed. Baltimore, Md: Williams & Wilkins; 1988:51-61. 9. Thorp JM, Seeds JW, Herbert WNP, et al. Prenatal management and congenital toxoplasmosis . N Engl J Med . 1988;319:372-373.Crossref 10. Roberts T, Frenkel JK. Estimated income losses and other preventable costs caused by congenital toxoplasmosis in the United States . J Am Vet Med Assoc . 1990;196:249-256. 11. Frenkel JK. Congenital toxoplasmosis: prevention or palliation . Am J Obstet Gynecol . 1981;141:359-361. 12. Frenkel JK. Toxoplasmosis . Pediatr Clin North Am . 1985;32:917-932. 13. Daffos F, Forestier F, Capella-Pavlovsky M, Thulliez P, Aufrant C, Valenti D. Prenatal management of 746 pregnancies at risk for congenital toxoplasmosis . N Engl J Med . 1988;318:271-275.Crossref
KOSKINIEMI, MARJALEENA;LAPPALAINEN, MAIJA;HEDMAN, KLAUS
1990 American Journal of Diseases of Children
doi: 10.1001/archpedi.1990.02150330014009
Abstract In Reply.—We appreciate Dr Frenkel's interest in our review article, and thank him for explaining the details of the direct agglutination test. The lack of correlation between titers and the severity of the disease is a property shared by all conventional antibody tests. To avoid iteration we mentioned it only once, in association with the standard Toxoplasma antibody assay, the Sabin-Feldman test. Underdiagnosis of congenital toxoplasmosis is the rule in children of all age groups. During the perinatal period, false-negative IgM results are common1-3 and the IgG antibodies may be either of maternal origin or due to intrauterine infection. Differentiation between these two conditions is thus far impossible. When IgG antibodies are detected in children over 6 months of age, differentiation between the acquired and congenital infection is also impossible, irrespective of the country. An "intelligently applied test" could, in principle, be exemplified by IgG antibody assays run References 1. McCabe R, Remington J. The diagnosis and treatment of toxoplasmosis . Eur J Clin Microbiol . 1983;2:95-104.Crossref 2. Desmonts G, Couvreur J. Congenital toxoplasmosis: a prospective study of the offspring of 542 women who acquired toxoplasmosis during pregnancy . In: Perinatal Medicine, 6: European Congress of Vienna, 1978 . Stuttgart, West Germany: Georg Thieme Verlag; 1979:51-60. 3. Stagno S. Congenital toxoplasmosis . AJDC . 1980;134:635-637. 4. Remington JS, Desmonts G. Toxoplasmosis . In: Remington JS, Klein JO, eds. Infectious Diseases of the Fetus and Newborn Infant . Philadelphia, Pa: WB Saunders Co; 1983;191-332. 5. Desmonts G, Couvreur J. Congenital toxoplasmosis: a prospective study of 378 pregnancies . N Engl J Med . 1974;290:1110-1116.Crossref 6. Alford CA Jr, Stagno S, Reynolds DW. Congenital toxoplasmosis: clinical, laboratory, and therapeutic considerations, with a special reference to subclinical disease . Bull N Y Acad Med . 1974;50:160-181. 7. Hedman K, Lappalainen M, Seppälä I, Mäkelä O. Recent primary Toxoplasma infection indicated by a low avidity of specific IgG . J Infect Dis . 1989;159:736-740.Crossref 8. Koskiniemi M, Lappalainen M, Hedman K. Toxoplasmosis needs evaluation . AJDC . 1989;143:724-728. 9. Ahlfors K, Börjeson M, Huldt G, Forsberg E. Incidence of toxoplasmosis in pregnant women in the city of Malmö , Sweden. Scand J Infect Dis . 1989;21:315-321.Crossref 10. Frenkel JK. Toxoplasmosis . Pediatr Clin North Am . 1985;32:917-932.
PIPER, MARTHA C.;PINNELL, LYNN;WELCH, BOB;DARRAH, JOHANNA;BYRNE, PAUL
1990 American Journal of Diseases of Children
doi: 10.1001/archpedi.1990.02150330016010pmid: 1697734
Abstract Sir.—The November 1989 issue of AJDC included an article by Susan Harris.1 We believe that Dr Harris used an inappropriate method in the calculation of the sensitivity and specificity rates for the Movement Assessment of Infants and Bayley Mental and Motor Scales, resulting in invalid rates. Harris had 3-year outcome data on 229 infants, including 36 with cerebral palsy, 75 who were developmentally delayed, and 118 who were normal. The 75 infants who were delayed at 3 years (32%) were not included in the analyses. Although these 75 infants presented diagnostic problems with their variable outcomes,2,3 they cannot be excluded from the analyses for the sake of simplicity. Sensitivity and specificity were accurately defined as, respectively, the percentage of abnormal cases correctly identified and the percentage of normal cases correctly identified. Obviously, sensitivity and specificity will vary depending on the value at which the screening test is References 1. Harris SR. Early diagnosis of spastic diplegia, spastic hemiplegia, and quadriplegia . AJDC . 1989;143:1356-1360. 2. Coolman RB, Bennett RC, Sells CJ, Swanson MW, Andrews MS, Robinson NM. Neuromotor development of graduates of the neonatal intensive care unit: patterns encountered in the first two years of life . J Dev Behav Pediatr . 1985; 6:327-333. 3. Piper MC, Mazer B, Silver KM, Ramsay M. Resolution of neurological symptoms in high-risk infants during the first two years of life . Dev Med Child Neurol . 1988;30:26-35.Crossref 4. Mausner JS, Kramer S. Epidemiology: An Introductory Text . Philadelphia, Pa: WB Saunders Co; 1985. 5. Sackett DL, Haynes RB, Tugwell B. Clinical Epidemiology: A Basis for Clinical Medicine . Boston, Mass: Little Brown & Co Inc; 1985. 6. Harris SR. Early detection of cerebral palsy: sensitivity and specificity of two motor assessment tools . J Perinatol . 1987;7:11-15.
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