Energy expenditure of children and adolescents with severe disabilities: a cerebral palsy model.

Spastic quadriplegic cerebral palsy (SQCP) is a severe disability that is associated with abnormal physical activity, body composition, and food intake and with frequent malnutrition. This study examined the pattern of dietary intake, anthropometry, and energy expenditure in a group of subjects with SQCP aged 2-18 y and a normal control group. The energy expenditure pattern was determined from resting energy expenditure (REE, n = 61 SQCP; n = 37 control group) by using indirect calorimetry and from total energy expenditure (TEE, n = 32 SQCP; n = 32 control group) by using the doubly labeled water method. Physical activity, including the chronic spasticity of SQCP, was estimated from the ratio of TEE to REE. Abnormal growth and body composition were common and dietary intake was markedly overreported in the children with SQCP. Children with SQCP were divided according to body fat stores determined by triceps-skinfold-thickness measurements. The children with low fat stores had a lower REE adjusted for fat-free mass compared with the SQCP and control groups with adequate fat stores. TEE was significantly lower for the SQCP group than for the control group. The ratio of TEE to REE, indicating energy for nonbasal needs, was significantly lower in the SQCP children than in the control group, with the adequately nourished SQCP children having lower ratios than the more poorly nourished SQCP group. The nonbasal energy expenditure, such as for physical activity and spasticity, of children with SQCP was low. The nutrition-related growth failure and abnormal pattern of REE are likely related to inadequate energy intake.

Factors associated with delay in diagnosis of childhood amblyopia.

The prevention of permanent visual impairment from amblyopia is an important goal of pediatric vision screening. Unfortunately, many cases of amblyopia are not diagnosed until the child is too old to benefit maximally from treatment. A review of patient records from the practice of a private pediatric ophthalmologist confirmed that late detection is a frequent occurrence among children with amblyopia who have had good access to health care. A case-control study was then used to identify factors associated with delayed diagnosis, in which children with an adverse outcome (diagnosed at or after 5 years of age) were compared with those with an optimal outcome (diagnosed before 5 years of age). The chart review identified 161 children with amblyopia who participated in this study; 75 had late diagnoses (case patients) and 86 served as control patients. Children with early diagnoses more often had the following characteristics: a positive family history of strabismus, greater degrees of strabismus (when strabismus was present), higher maternal educational level, greater parental suspicion that an eye problem existed, and an increased chance that the parents requested the eye examination that led to the diagnosis. The parents of children with late diagnoses expressed less concern over the seriousness of amblyopia but were more likely to report that their children had suffered adverse consequences of amblyopia. When diagnosed early, amblyopia was more often detected by the child's primary health care provider. Physicians of the children with early diagnoses more often reported compliance with both the American Academy of Pediatrics guidelines for vision screening in infancy and referral for vision problems.(ABSTRACT TRUNCATED AT 250 WORDS)

Increased lead absorption in inner city children: where does the lead come from?

Pica for lead-containing paint has been questioned as the principal mechanism for the widespread moderately elevated blood lead levels (30 to 80 microgram/100 ml) in inner city children. This study explored the hypothesis that lead-contaminated household dust is a major source of lead for these children; hand contamination and repetitive mouthing is the proposed mechanism of ingestion. Forty-nine inner city children with blood lead 40 to 70 microgram/100 ml were matched with 50 children with blood lead less than or equal to 29 microgram/100 ml from the same inner city environment. House dust lead and lead on hands were found in significantly greater quantity among experimental subjects. Other factors differed between groups; lead content of peeling paint, soil lead, and pica affected more experimental than control children, but did not account for more than 50% of experimental cases. The cause of moderate blood lead elevation is multifactoral: no single source accounted for all children with elevated levels. However, lead contamination of house dust and hands appears to be a major factor in this condition.

Compliance with short-term antimicrobial therapy: some techniques that help.

The effect of two reminder devices on compliance with a ten-day antimicrobial prescription was investigated in a health center population. The reminders, a clock printed on the prescription label with appropriate times circled and a 5 X 7 inch bright red sticker to be posted at home, were compared to a control group. A total of 158 patients were interviewed at home on the ninth or tenth day of therapy, and compliance estimated by measuring the amount of remaining medication. For children, both reminders improved compliance about two-fold over controls. The findings suggest that (1) several simple reminder devices can be effective and (2) the nature of the patient population may be a more important influence on compliance than the relationship to a physician or the type of health care system. In addition, the study demonstrates the influence of the pharmacist on patients' medication-taking behavior.

A successful city-wide smoke detector giveaway program.

Each year, 5,000 Americans die and 300,000 are hospitalized as a result of 2.8 million residential fires. Almost all house fires allow time for safe exit if an early warning is given. Smoke detectors are an effective, reliable, and inexpensive method of providing such warning. After an upsurge of deaths related to fires in 1982, Baltimore City gave away 3,720 smoke detectors to households that requested them. This study addressed two questions: (1) Did the households that received the smoke detectors install them? (2) Was the population reached by this giveaway program a population at high risk from fire? A survey of 231 randomly selected households among those requesting smoke detectors was conducted 8 to 10 months after the giveaway program. At that time, smoke detectors were installed in 92% (212/231) of the homes and 88% (187/212) of the installed smoke detectors were operational. Households requesting smoke detectors were in census tracts at higher risk from fire. The correlation coefficient between the rate of requesting a smoke detector and the risk of death or injury related to fires was r = .90, P less than .001. The 231 surveyed households had more personal fire risk factors than the general population. The success of this smoke detector giveaway program is notable in that it required the active participation of a high-risk population.

Childhood physical fitness tests: predictor of adult physical activity levels?

Regular physical activity has both short- and long-term health benefits in adults. No study has investigated childhood determinants of adult physical activity patterns, however. In a nonconcurrent prospective study, the physical activity levels of 453 young men, 23 to 25 years of age, were compared with their physical fitness test scores as children (10 to 11 years of age and 15 to 18 years of age). The physically active adults had significantly better childhood physical fitness test scores than did the inactive adults. In 224 children, 2 years of fitness test results were available. The risk of physical inactivity in young adulthood was linearly related to the number of low scores on the 548.6-m (600-yd) run and sit-ups tests as children (P less than .001). In stepwise multivariate discriminant analysis, the childhood 548.6-m run score was the best discriminator between currently physically active and inactive adults. Reported parental encouragement of exercise, level of education, participation in organized sports after high school, and reported spousal encouragement of exercise also contributed significantly to the discriminant function. These results demonstrate that physical fitness testing in boys facilitates the identification of those at increased risk of becoming physically inactive young adults.

Management of the newborn with myelomeningocele: time for a decision-making process.

The relationship between time of surgical intervention and eventual outcome was examined in 110 newborns with myelomeningocele. Numerous earlier reports have cited a significant increase in mortality and morbidity associated with delay of surgery beyond 48 hours. Within the study population of infants, 52 infants (47%) had "early" surgery within the first 48 hours of life, 32 infants (29%) had "delayed" surgery between 3 and 7 days of age, 12 infants (11%) had "late" surgery between 1 week and 10 months of age, and 14 infants (13%) never had surgery by parental decision. Survival rates were similar between those with early, delayed, or late surgery as 92%, 94%, and 100%, respectively, were alive at age 10 months. Also, no significant association existed between time of surgery and development of ventriculitis, developmental delay, or worsening of paralysis. From these observations, it is concluded that there is no urgency in surgical intervention for the initial management of newborns with myelomeningocele. Rather, there is time for comprehensive discussions, counseling, and emotional support for those parents in need of a decision-making process before establishing consent for or against surgical management of their newborn.

Changing patient management: what influences the practicing pediatrician?

To explore some determinants of physicians' decisions to change practice habits, we posed three questions: To what extent are some particular innovations diffused among office-based primary care physicians? What characterizes the physicians who have adopted these innovations? And, what caused them to change their behavior and adopt the innovations? Three "markers," recent innovation in medical practice, were chosen using an expert consensus technique. A telephone survey of 200 office-based pediatricians was conducted, and the physicians were asked whether or not they used the following three innovations in medical practice: continuous rather than intermittent phenobarbital for the prevention of febrile seizures, glycosylated hemoglobin measurement in the management of diabetes, and slow release theophylline in the management of asthma. The questionnaire was completed by 156 pediatricians. Of the 110 pediatricians who cared for diabetics, 73% used glycosylated hemoglobin measurement; of the 145 who saw patients with febrile seizures, 77% prescribed the continuous use of phenobarbital (if they used it at all); and, of the 152 pediatricians who cared for asthmatics, 86% reported using slow-release theophylline. The characteristics significantly associated with using the innovations were board certification, group rather than solo practice, teaching, medically related publications, academic appointment, younger age, and caring for a greater number of patients per week. For two of the innovations, discussion with a colleague was the most important source of information leading to a change of practice. The subjects cited local specialists as the colleagues who most often sparked the adoption of an innovation.

Prevention and therapy of serous otitis media by oral decongestant: a double-blind study in pediatric practice.

We studied the efficacy of (1) preventing the development of serous otitis media (SOM) by using an oral decongestant in children with acute otitis media and (2) treating SOM with an oral decongestant. In a randomized double-blind study, 190 children were treated for acute otitis media with antibiotics and either pseudoephedrine hydrochloride (Sudafed) or placebo. They were evaluated two weeks later by tympanometry and (independently) by clinical evaluation and pneumotoscopy. There were no significant differences between the two groups, except that males developed SOM significantly more often than did females. Use of decongestant and placebo was continued in 78 patients with SOM for up to four more weeks. Again, there were no siginificant differences between the treatment groups except that patients with an allergic history did significantly worse using a decongestant. Overall there was no benefit from pseudoephedrine in either the prevention or treatment of SOM.

Obstetric, neonatal, and psychosocial outcome of pregnant adolescents.

Obstetric, neonatal, and psychosocial outcomes were compared for 82 matched adolescents who had been pregnant, been delivered of an infant, and received health care in three sites in Rochester, New York. There were no major differences in obstetric and neonatal outcome of adolescents and their babies according to health site. Differences in outcome were expected in the psychosocial area where a specialized maternity project (Rochester Adolescent Maternity Project [RAMP]) offered more services. On follow-up two years later, school attendance and reliance on full or partial assistance were similar. Repeated pregnancy and postpartum use of contraception favored RAMP.

Lead analysis of house dust: a method for the detection of another source of lead exposure in inner city children.

A method has been developed to test the hypothesis that lead-containing house dust is responsible for the elevated levels of lead in blood of inner city children. Dust analyses of smears from the floors, walls, and windowsills in low-income inner city dwellings have shown a median concentration of lead five times as high in suburban homes. It is suggested that lead-containing dust may be one of the most important environmental sources of increased lead exposure in this specific population group.

Preliminary observations on maternal rating of health of children: data from three subspecialty clinics.

Although routinely used in health surveys, the factors affecting maternal perceptions of health in children, especially those with health problems, have received little examination. This question has been addressed using a telephone interview of families of 483 children followed in one of three clinics at Children's Hospital of Philadelphia: the Neonatal Follow-up Program, the Pediatric Rheumatology Center and the Spina Bifida Program. Limitations in activities of daily living due to the health of the child, medical care use and variables indicative of socio-economic disadvantage were associated with a maternal rating of child health as fair/poor in all groups. The relationship was strongest in the rheumatologic group and less strong in the other two, suggesting that mothers may distinguish between a chronic active disease in a previously healthy child and the disability following a neonatal event in conceptualizing health. The results add to our information about maternal perceptions in assessing child health and suggest ways in which such ratings may prove useful in assessing health and health services for children with health problems.

The role of the ionic environment in the orientation of nucleic acids in electric fields.

The relationship between polyelectrolyte theories based on linear charge density models and the electric-field induced orientation of the polyelectrolytes, poly(A), poly(C) and DNA is examined by varying their ionic environment with respect to ionic strength and acidity. The degree of counterion condensation on the polyelectrolytes predicted by the theories of Manning and Record is shown to be related linearly to the orientation as measured by their dichroism in the field. Micro-structural differences between poly(A) and poly(C) account for the differences in their dependence on the pH of the medium which affects the counterion condensation and thus the polarization in the orienting electric fields. The results consequently support recent treatments of linear polyelectrolytes having a high charge density which model them as smoothly charged linear polyions, but indicate that these models are insufficient to account for some of the effects of microstructural variations.

Electric dichroism of DNA. Influence of the ionic environment on the electric polarizability.

In order to test the diffuse ion atmosphere polarization model recently developed by us, the effects of ionic strength, titrating with Mg2+ and Co(NH3)3+6, and coion charge on the electric polarizability of short fragments of DNA are investigated. The results are consistent with the predictions of the theory and show that the diffuse ion atmosphere polarization contributes significantly to the overall orientation of DNA. At low ionic strengths, we attempt to separate the total dipole moment into two components: one that agrees well with the Debye-Hückel ion atmosphere calculations, while the other, presumably due to condensed counterion polarization, appears to be substantially independent of the ionic strength. At higher salt concentrations, however, a simple separation into dipole components is not possible, perhaps due to a significant coupling of ion flows between the diffuse atmosphere and the condensed counterion layer.

Polarization of the ion atmosphere of a charged cylinder.

The dipole moment is calculated for an electric-field-induced polarization of a Debye-Hückel ion atmosphere surrounding a charged rod. If L is the length of a thin rod. Q is its linear charge density, Z is charge of the salt ion in solution, and k is the Debye-Hückel shielding parameter, then for KL less, similar 10, the calculated polarizability is proportional to Z(2)Q(2)L(1.8)/K(1.2). Comparison with experimental data for DNA shows that the ion atmosphere dipole is of the correct magnitude and is consistent with observed variations with Z, Q, L and k.

Ionic strength and counterion repulsion as factors in the behavior of polyions in orienting electric fields.

The effect of counterion-counterion repulsion on the orientation of DNA, a polyion of high charge density is examined by electric-field orientation experiments. The charge species of the counterion and the ionic strength effect the orientation in a manner consistent with a theoretical treatment of the polarization of high charge density polyelectrolytes in terms of the effect of the applied field on the equilibrium distribution of condensed counterfoils on the polyion.

Family practice, internal medicine, and pediatrics as partners in the education of generalists.

The generalist of the future will play an integral role in the health care delivery system, yet the three recognized generalist specialties have developed and functioned along largely separate tracks. No matter what form of generalism evolves, family practice, internal medicine, and pediatrics must begin to cooperate and collaborate in developing new graduate medical education programs that are sufficiently flexible to meet whatever emerges in the future. They must devote their energies to working together, rather than competing; to emphasizing those parts of their programs that have similarities; and to sharing their knowledge, skills, attitudes, and perspectives about the care of patients. They must develop training experiences in which residents will obtain maximum contact with a wide variety of problems and patients in many different settings; a substantial portion of such training should be generic and virtually interchangeable among the three specialties. As the health care system evolves, so should these disciplines; they must begin to "train physicians to provide continuing, comprehensive and coordinated medical care to a population undifferentiated by gender, disease or organ system," as urged by the American Boards of Family Practice and Internal Medicine.

Symptomatic Arnold-Chiari malformation: review of experience with 22 cases.

Twenty-two patients with closed myelomeningoceles, shunted hydrocephalus, and symptomatic Arnold-Chiari malformations were studied retrospectively. Seventeen of the 22 patients were aged 6 months or younger; five patients were aged 3 to 23 years. Patients in the younger group presented with stridor, apnea, and/or feeding difficulty; those in the older group presented with hemiparesis, quadriparesis, oscillopsia, nystagmus, or opisthotonos. Fourteen of the 17 younger patients underwent surgical decompression of the Arnold-Chiari malformation: 10 within 18 days following the onset of symptoms and four on Day 19 or later. Of the 10 infants with early treatment, five eventually died secondary to continued symptoms and five survived. Of those surviving, three were asymptomatic and two had continuing symptoms but were improved over their preoperative state. Among the four patients undergoing surgery later, two died, one had lessening of stridor, and one had complete relief of symptoms. Of the three infants not undergoing decompression, two died and one eventually became asymptomatic. All five of the older patients underwent decompression and all had complete resolution of their preoperative symptoms and signs. The authors conclude that while decompression of a symptomatic Arnold-Chiari malformation may be effective in children and adults, this treatment does not always improve the clinical condition of infants. This may be the result of ischemic/hypoxic effects on the infant's brain stem, which may not be organized normally at birth.

The flexibility of alternating dA-dT sequences.

The flexibility of alternating poly (dA-dT) has been investigated by the technique of transient electric dichroism. Rotational relaxation times, which are very sensitive to changes in the end-to-end length of flexible polymers, are determined from the field free dichroism decay curves of four, well defined fragments of poly (dA-dT) ranging in size from 136 to 270 base pairs. Persistence lengths, calculated from the results of Hagerman and Zimm (Biopolymers (1981) 29, 1481-1502), are in the range 200-250 A. This makes alternating dA-dT sequences about twice as flexible as naturally occurring, "random" sequence DNA. Considering a bend around a nucleosome, for example, this difference in persistence length translates to an energy difference between poly (dA-dT) and random sequence DNA of 0.17 kT/base pair or 1 kcal per 10 base pair stretch. This energy difference is sufficiently large to suggest that dA-dT sequences could serve as markers in DNA packaging, for example, at sites where DNA must tightly bend to accommodate structures.