Takayasu's arteritis: the relationship with tuberculosis.

A 12-year-old girl developed Takayasu's arteritis (pulseless disease) within a month of the appearance of tuberculous cervical adenitis. This unusual form of arteritis is common in Japan and Korea but has rarely been reported in individuals born in the United States. The etiology is unclear. The literature currently hypothesizes an autoimmune basis and treatment with steroids. Although a tuberculin sensitization pathogenesis has been suggested, a close temporal relationship with the onset of a tuberculous process has not previously been documented. The likelihood of uncovering tuberculin sensitivity or active tuberculosis in patients with Takayasu's arteritis is substantially higher than in the general population in all countries analyzed. The natural history of this arteritis is highly variable. The adolescent described in this paper has demonstrated complete symptomatic remission as well as return of pulses simultaneous with antituberculosis therapy.

Adolescent chest pain: a prospective study.

One hundred adolescents with chest pain were prospectively analyzed to determine the etiology, functional consequences, and illness attributions of patients seen in a general pediatric clinic. The typical patient had frequent pain (63% had two or more episodes weekly) of moderate duration (51% of the pain lasted longer than six minutes) that had been occurring for many months (36% had pain occurring longer than 6 months). Stressful events, such as a death in the family, major illness, an accident, family separations, and school changes occurred in 31% of patients. The most frequently diagnosed condition was musculoskeletal problems (31%) including costochondritis (14%), chest wall syndrome (13%), skeletal trauma (2%), and ribcage anomalies (2%). Hyperventilation accounted for 20% of diagnoses and 5% had breast-related problems. Thirty-nine percent of patients had pain not readily classifiable. Serious underlying illness was a rare cause of chest pain, although several patients had associated organic disease not responsible for their chest pain. More than two thirds of patients restricted physical activities; more than 40% were absent from school. When patients were questioned about their understanding of their illness, 44% were afraid that they were experiencing a heart attack, 12% worried about heart disease, and 12% feared cancer. Chest pain is a prevalent problem that is usually benign but is commonly misunderstood and causes considerable dysfunction and anxiety in adolescents.

Increasing patient knowledge, satisfaction, and involvement: randomized trial of a communication intervention.

A brief educational intervention to promote effective communication between physicians, children, and parents during pediatric office visits was designed and tested. A randomized clinical trial involving 141 children (5- to 15-year-olds) tested the effectiveness of the intervention to improve the process and outcome of medical care. The intervention was contained in three brief videotapes (one each for parents, physicians, and patients) and in accompanying written materials. Materials were designed to build skills and motivation for increased child competence and participation during pediatric medical visits. Control subjects saw health education videotapes and received materials comparable in length with those of experimental subjects. Postintervention medical visit process was analyzed using videotapes of visits. Visit outcomes, assessed with standardized instruments and interviews, included children's rapport with physicians, children's anxiety, children's preference for an active health role, children's recall of information, parents' satisfaction with the medical visit, and physician satisfaction. Results indicated that physicians in the intervention group, compared with their counterparts in the control group, more often included children in discussions of medical recommendations (50% vs 29%, t = 2.39, P less than .05); that children in the intervention group, compared with control children, recalled more medication recommendations (77% vs 47%, P less than .01) and reported greater satisfaction and preference for an active health role; and that the intervention and control groups did not differ in parent satisfaction, physician satisfaction, or child anxiety. The results suggest that a brief educational intervention administered during waiting room time can positively impact physician-child rapport and children's preference for an active role in health and their acquisition of medical information.

Psychosocial problems during child health supervision visits: eliciting, then what?

An explicit goal of child health supervision visits is to gather information and provide guidance about the psychosocial problems of children and families. The purpose of this study was to determine the extent to which parents had opportunities to express psychosocial concerns and the nature of physicians' responses to these concerns during health supervision visits. The authors analyzed videotapes of child health supervision visits by 34 children aged 5-12 years to 34 pediatric and family medicine residents. Coding systems with acceptable interobserver reliability were developed to assess (1) the nature of opportunities provided to express concerns, (2) categories of psychosocial problems expressed by parents and children, and (3) the nature of physicians' responses. In 88% of the child health supervision visits, opportunities were created by the physician to discuss psychosocial concerns or were spontaneously raised by the parent or child. In half of the visits, parents or children expressed a total of 30 psychosocial concerns. Psychosocial problems raised included conduct/behavior problems (47%), insecurity (13%), family, sibling, or social problems (13%), learning difficulties (10%), somatization (7%), and other (10%). Physicians' responses to these psychosocial concerns were as follows: 17% ignored the concern; 43% asked further exploratory questions but provided no information, reassurance, or guidance; 3% reassured the parent; 27% responded with psychosocial information and/or action; 3% responded with medical information and/or action; and 7% responded with a combination of these latter two modes of actions. Pediatric residents were more likely to respond to more disruptive behavioral concerns (r = .60, P less than .05).(ABSTRACT TRUNCATED AT 250 WORDS)

Physician communication with children and parents.

The way physicians communicate with patients has been shown to affect physiologic measurements, adherence to therapeutic regimens, and satisfaction with medical care. The purpose of this study was to document the content of medical interviews in routine pediatric visits and to identify demographic and situational characteristics that influenced the extent of communication between doctor and child. One hundred fifteen office visits to 49 physicians were videotaped and analyzed. Children studied were 4 to 14 years old with a mean age of 8.5 years. Verbal transactions were coded according to direction of communication, transaction type, and content category. Coder reliability for this system was 0.84. A considerable amount of the total communication, 45.5%, was between doctor and child. Doctors interacted differently with parents and children. More information about the current problem was obtained from children; physicians provided feedback primarily to parents. Parents received 4.4. times as much information as children about the nature and prognosis of a condition. The extent to which doctors talked to children in "substantive" areas was primarily associated with a child's age (r = .52, P less than .001) but was partly influenced by family size (r = .20, P less than .05) and family utilization (r = .22, P less than .02). Race, socioeconomic status, type of problem, and previous encounter with the examining physician did not alter communication patterns. Boys were given more information than girls (6.5% vs 4.0%, P less than .01). We suggest a theoretical framework for future investigation and teaching that identifies the child as an active participant in the medical process.

Is the routine pelvic examination needed with the advent of urine-based screening for sexually transmitted diseases?

OBJECTIVE: To determine the most cost-effective method of screening for chlamydia and gonorrhea to prevent pelvic inflammatory disease (PID) in asymptomatic sexually active adolescent females. DESIGN: Cost-effectiveness decision analysis comparing pelvic examination with cervical screening (the current national standard) with a model of urine screening with ligase chain reaction testing for Chlamydia trachomatis and Neisseria gonorrhoeae. METHODS: Four strategies using decision analysis were compared for a potential cohort of 100000 asymptomatic sexually active young women: (1) pelvic examination screening in 100%; (2) urine screening in 100%; (3) actual predicted pelvic examination screening in 70%; and (4) actual predicted urine screening in 90%. Assumptions and costs were generated from published sources. MAIN OUTCOME MEASURES: Cases of PID prevented per year and cost to prevent a case of PID. RESULTS: A total of 1750 cases of PID would be predicted to occur per year with no screening. Strategy 1 would prevent the most cases of PID (1283) at a mean cost of $10230. Strategy 2 would prevent 1215 cases of PID at a mean cost of $5093. The marginal cost to prevent an additional case of PID by strategy 1 is $101454. Strategy 3 would prevent 898 cases of PID and 1093 cases of PID would be prevented with urine screening in strategy 4. CONCLUSION: Urine-based ligase chain reaction screening is the most cost-effective strategy to detect chlamydial and gonococcal genital infection in asymptomatic sexually active adolescent females and, owing to ease of implementation, the most likely to prevent the greatest number of cases of PID.

Gender differences in physician-patient communication. Evidence from pediatric visits.

OBJECTIVE: To determine whether physician gender and patient gender influence the process of communication and parent and child satisfaction during pediatric office visits. DESIGN: Content analysis of videotaped pediatric office visits. SETTING: University-based pediatric primary care practice. SUBJECTS: Videotaped communication between 212 children, ages 4 to 14 years, parents, and physicians. Thirty-eight percent were child health supervision visits, and 62% were for the management of minor or chronic illnesses. MAIN OUTCOME MEASURES: An established coding system of physician-patient communication and measures of parent and child satisfaction with medical care. RESULTS: Female physician visits were 29% longer than those of male physicians (P < .001). Compared with male physicians, female physicians engaged in more social exchange (P < .01), more encouragement and reassurance (P < .01), more communication during the physical examination (P < .05), and more information gathering (P < .01) with children. Male and female physicians engaged in similar amounts of discussions regarding illness management. Children were more satisfied with physicians of the same gender (P < .05), while parents were more satisfied with female physicians (P < .05). CONCLUSIONS: Children communicate more with female than with male physicians and show preferences for physicians of the same gender. These findings are consistent with communication patterns in adult patients and may have a significant influence on gender disparities in health care. Efforts at improving the process and outcome of medical care should address gender differences.

Health care of children and adults with acquired immunodeficiency syndrome. A population-based analysis.

OBJECTIVES: To compare the use of medical services by pediatric and adult patients with acquired immunodeficiency syndrome (AIDS) in the 6 months before and after the diagnosis of AIDS when demand for care is often high and to study the influence of human immunodeficiency virus specialty care on survival of pediatric patients. DESIGN: Retrospective analysis of Medicaid files. SETTING: New York State Medicaid Program. PATIENTS: A cohort identified as having AIDS from 1985 through 1990 and enrolled on Medicaid from birth or 1 year or more before diagnosis. Because of differing prognoses, 3 groups were studied by age at the time that AIDS was diagnosed: infants younger than 6 months, children aged 6 months to 12 years, and adults aged 13 to 60 years. MAIN OUTCOME MEASURES: Frequencies of any service use and, among users, monthly rates of services. From Cox proportional hazards models, the adjusted hazard of death for human immunodeficiency virus specialty ambulatory care. RESULTS: Nearly all infants (n = 122) were hospitalized before and after the diagnosis of AIDS was made--the most of all groups. After diagnosis, only 81% of older children (n = 612) were hospitalized vs 93% of infants and 90% of adults (n = 5602). Hospitalized children had a median of only 3.3 inpatient days per month vs 12.3 and 7.8 inpatient days for infants and adults, respectively. Of older children, 45% used the emergency department vs 33% of adults. Human immunodeficiency virus specialty care for infants and children was associated with a 40% lower risk of death after the diagnosis of AIDS. CONCLUSIONS: In this AIDS cohort, infants had the greatest use of inpatient care, and older children used the emergency department more than adults. The finding of improved survival for infants and children with human immunodeficiency virus specialty care warrants further study in more recent years.

Noninvasive digital energy subtraction angiography with a channeling-radiation x-ray source.

Channeling radiation could provide a viable source for digital energy subtraction angiography (DESA). A signal to noise ratio (SNR) of 6.2 for a resolution of 0.5 mm x 0.5 mm could be achieved using a 6-mA 100-ms 20-MeV electron-beam pulse and a diamond channeling crystal as the x-ray source. This article investigates the choice of a DESA contrast agent and the parameters of a channeling-radiation x-ray source to develop a channeling-radiation DESA imaging system. The production of dual-energy peaks, the maximum available x-ray flux, the advantages of an area exposure, the necessity of a mosaic Bragg-crystal filter to reduce patient dose, the optimal energy separation of the peaks for a quasi-monochromatic x-ray source, and the reduction of the signal from bone are discussed, leading to estimated SNRs and image resolution for a channeling-radiation imaging system. The computer analysis developed to calculate the image quality is also discussed.

Analysis of the reasons for the high turnover of clinicians in neighborhood health centers.

A high rate of turnover of professional personnel in a clinic is disruptive to patient care and organizational stability as well as to the individual clinician. The turnover rate for clinicians (physicians, nurse practitioners, and physician assistants) working in neighborhood health centers (NHCs) is considerably higher than that for clinicians in other forms of practices. All 10 of the neighborhood health centers in HEW (Department of Health, Education, and Welfare--now the Department of Health and Human Services) Region X (Alaska, Idaho, Washington, and Oregon) that offered a full range of medical services provided information about the clinicians that they had employed since their inception. One hundred and one clinicians were surveyed about their work experience. The vast majority of those clinicians who had left a neighborhood health center remained in the community; they cited organizational issues as being at the heart of their dissatisfaction with the centers. Clinicians who began work during the initiation of a clinic remained significantly longer. The results suggest the immediate need for a strategy directed at the smooth organizational evolution of each NHC right from its inception.

Construction of a Cerenkov light source.

A radiation source has been developed and implemented from Cerenkov emission that is intended to provide an intense continuum from the infrared to 600 A. Parasitic use of the primary electron beam at the Stanford Linear Accelerator Center (SLAC) together with a novel optical geometry for light collection can give a focused and tunable ultraviolet beam with 10(4) kW/m(2)sr brightness, 10(-2) spectral purity, and with the pulsed, 5 ps time structure of the SLAC electron beam. Measurements of emission characteristics in the visible part of the spectrum correlate closely with the predicted performance.

Fever in the first six months of life: risks of underlying serious infection.

The age-specific rate of elevated temperature over 37.8 C was evaluated in all infants less than 6 months of age (n = 1341) seen from July 1, 1974 to June 30, 1978 in a family practice clinic. Mild elevations (37.8 C-38.3 C) were common even in the first few months of life, and accounted for 20.7 per cent of infant visits. Temperatures greater than 38.3 C are uncommon in the first months of life but are seen more frequently with each succeeding month. Temperature elevation over 38.3 C was associated with a significantly higher rate of meningitis (p less than .01), otitis media (p less than .001) and lower respiratory infection (p less than .05). Significantly higher laboratory usage was documented in infants less than 3 months and for infants with temperature more than 38.3 C. The high rate of mild temperature elevations in young infants suggests that a selective diagnostic strategy directed at high-risk infants is important. Infants less than three months of age with a fever exceeding 38.3 C are calculated to have 21.5 times the risk of a serious underlying infection as infants older than three months with a similar temperature elevation. Clinical evaluation must remain an important tool in determining which febrile infants should be evaluated by further laboratory and diagnostic tests.

Body temperature of newborns: what is normal?

Medical records of 203 healthy full-term infants were reviewed to determine the range of axillary temperatures for newborn infants, factors that affect temperature and nursery management of infants with temperatures outside published normal ranges. The mean birth temperature was 36.5 degrees C (S.D. = 0.6 degrees C). Temperature was associated with birth weight (p<0.0005) and the presence of maternal fever (p<0.0001) but not with type of environment or time of birth. The mean temperature increased with age, rising 0.2 degrees C by 2-3 hours after birth (p<0.0001) and 0.3 degrees C by 15-20 hours (p<0.0001). Among a subset of 114 eligible neonates the mean temperature dropped 0.2 degrees C after bathing (p<0.0001). Although 17% of all temperatures measured were in the hypothermic (< or =36.3 degrees C) range, the only response recorded by nursery staff consisted of warming by modifying the environment, e.g., bundling. Blood cultures were drawn from 51 infants (25%), 43 because of maternal intrapartum antibiotic treatment for maternal fever or prolonged duration of ruptured amniotic membranes (>24 hours) and none for evaluation of abnormal temperatures. No infants had systemic infections and all were discharged in stable condition. Newborn axillary temperatures in our nursery were considerably lower than what has been previously described as "normal." Given the frequency of "hypothermia" and absence of associated illness, we believe the reference range for newborn temperatures should be expanded to include lower temperatures.

Children as patients: a communications process study in family practice.

To determine how family physicians divide their attention between children and parents, 115 videotaped pediatric encounters of children (aged 4 to 14 years) and parents with family physicians in a family medicine center were analyzed. It was learned that physicians tended to involve children actively in the diagnostic stages of interviews but much less so in discussions of treating or dealing with their problems. Physicians did not alter this pattern as they advanced in training. Older children were more likely to receive direct communication from physicians in all phases of office encounters. Though the family physicians in this sample had more direct communication with children than reported in previous research, it is argued that greater involvement of children in all phases of pediatric visits is warranted. A developmental framework indicates that children gradually evolve their attitudes, concepts, and behaviors around illness and health. Family physicians and family medicine programs are in an excellent position to explore and utilize the practice of actively incorporating a child in a medical interview.

Periodic magnetic field as a polarized and focusing thermal neutron spectrometer and monochromator.

A novel periodic magnetic field (PMF) optic is shown to act as a prism, lens, and polarizer for neutrons and particles with a magnetic dipole moment. The PMF has a two-dimensional field in the axial direction of neutron propagation. The PMF alternating magnetic field polarity provides strong gradients that cause separation of neutrons by wavelength axially and by spin state transversely. The spin-up neutrons exit the PMF with their magnetic spins aligned parallel to the PMF magnetic field, and are deflected upward and line focus at a fixed vertical height, proportional to the PMF period, at a downstream focal distance that increases with neutron energy. The PMF has no attenuation by absorption or scatter, as with material prisms or crystal monochromators. Embodiments of the PMF include neutron spectrometer or monochromator, and applications include neutron small angle scattering, crystallography, residual stress analysis, cross section measurements, and reflectometry. Presented are theory, experimental results, computer simulation, applications of the PMF, and comparison of its performance to Stern-Gerlach gradient devices and compound material and magnetic refractive prisms.

Appendectomies during physicians' boycott. Analysis of surgical care.

The 1975 San Francisco physicians' boycott caused major changes in patterns of providing surgical care, but there was no appreciable change in the number of appendectomies performed during the boycott month when compared with a six-month baseline period. The ratio of normal to inflamed appendices removed was no different during the boycott than it was during the control period, and no differences were noted in the percentage of cases perforating in the boycott month when compared with the control period. In addition, patients seeking care for appendicitis during the boycott month did not experience delays. The lack of change in the standard direct and indirect indicators used to monitor quality of care suggests no major lapses in appendicitis care occurred in San Francisco during the boycott.

Influence of surface roughness on the propagation of x rays through capillaries.

Calculations have been performed to determine the effect of surface roughness on the propagation of x rays through hollow capillaries. The analysis is based upon assuming an expression for the form of the power reflected from a single bounce of the light and then on obtaining the power in a waveguide by repeated application of this expression. Data from single reflection measurements on highly polished surfaces have been used to show that surface roughness should have little effect on wave propagation.