The children's hour: the State Children's Health Insurance Program.

The State Children's Health Insurance Program (CHIP) is the product of a series of policy and political compromises and generates numerous structural and policy issues for states. CHIP entitles states to federal financial aid to provide health assistance to targeted children, through Medicaid expansions, new program implementation, or a product of the two. States that elect to operate CHIP programs apart from Medicaid have enormous discretion under the law to determine how they will structure their programs, the services they will cover, the form that benefits will take, and the conditions of participation and consumer protections that will apply. Determining what approach to take, as well as how to respond to the choices posed by the statute, represents a major test of how states address the needs of children and families.

Tuberculosis in Louisiana: an update.

The incidence of tuberculosis in the United States declined steadily until 1985 when increases were seen, in part due to the AIDS epidemic. Although the decline resumed in 1992, tuberculosis remains a public health problem in Louisiana and nationally. In Louisiana in 1997, HIV infection was present in 14% of persons with tuberculosis whose HIV status was known. In that year there were 16 cases of tuberculosis that were resistant to at least one first-line anti-tuberculous drug. Infection with Mycobacterium tuberculosis is diagnosed with the tuberculin skin test; the size of induration considered positive varies with the risk status of the person tested. TB infection in immunocompetent persons under age 35 is treated with 6 months of isoniazid. TB disease is generally treated with 4 drugs until antimicrobial sensitivities are known. Directly observed therapy is an inexpensive way to ensure compliance and is routinely used for patients in Louisiana.

Epizootic of Mycobacterium bovis in a zoologic park.

An epizootic of Mycobacterium bovis in a zoologic park resulted in the death of 4 southern white rhinoceroses and 2 colobus monkeys. Zoo personnel were detected that had positive intradermal tuberculin skin test results after exposure to mycobacterial-infected animals. On the basis of DNA fingerprinting, all 3 mycobacterial isolates (from 1 rhinoceros and 2 monkeys) were determined to be genetically similar and probably originated from the same source. The 3 animals (1 rhinoceros and 2 colobus monkeys) that had confirmed infections lived in separate, but adjacent, areas. Aerosolization of bacteria during routine cleaning was believed to have contributed to the unusual distance between infected animals. Tuberculosis has reemerged as a major disease problem in human and veterinary medicine.

Attacking today's tuberculosis problem: a multifaceted, coordinated effort.

Tuberculosis is making a comeback in communities across the nation. Increased rates of the disease, particularly with those having HIV/AIDS, have sounded the alarm that quick and decisive action is needed to halt the spread of TB. Multidrug-resistant TB is becoming a primary concern with public health officials. Specific plans and efforts, instigated by the Centers for Disease Control, have outlined the appropriate steps local public health workers, the medical community, and civic and community organizations should take in order to eliminate TB by the year 2010. With the creation of the Task Force on Drug Resistant Tuberculosis, Louisiana has a vehicle with which to combat its growing TB problem.

Healthy children ready to learn: an essential collaboration between health and education.

The "Healthy Children Ready to Learn" initiative starts with the underlying concept that health is a critical partner to optimum education. All children have a right to be healthy. At a minimum, this right assumes promoting optimum use of available and effective preventive measures, such as ensuring compliance with immunization recommendations; promoting measures to prevent injuries; ensuring opportunities to identify disease and disabilities early; and providing prompt treatment when needed. Families must receive the support and assistance they need to raise healthy and educated children. Activities directed toward National Education Goals and the related National Health Promotion and Disease Prevention Objectives can advance progress toward school readiness, focus attention and available resources on needed programs and services, and thus help the nation in achieving its goal of having all children arriving at school each day healthy, well nourished, and ready to learn. To realize these goals and objectives, the two critical systems of greatest importance to children, those providing health services and education, need to collaborate, not only among themselves, but also with social services. A range of critical health problems will require our attention if the goals are to be met, such as availability of prenatal care, infant mortality, inadequate nutrition during pregnancy or early childhood, or both, disease prevention by immunization, infants who have been exposed to drugs, fetal alcohol syndrome, and the emotional and mental disorders of early childhood, to name a few. At any one time, any family may be in need of appropriate services. To address the health and well-being of their young children, a continuum of appropriate, accessible services must be available in the community. The first steps toward successful achievement of the readiness goal will require the identification of health, education, and social service programs that serve young children and their families, and the creation of a climate that fosters innovative and effective collaboration between programs at the Federal and State levels, especially as it pertains to the community. Policies and programs should be built around the needs of families. In this regard, the critical role that parents play in shaping a healthy environment conducive to school readiness must be recognized as a key element in shaping the strategies that should help in achieving the readiness goal. Similarly important is the need to engage professional organizations and other private sector groups involved with health, education, and other children's issues to work with government and families to achieve the school readiness goal and its related health objectives.

The school-age child: putting it all together.

The school-age period offers many opportunities to the pediatrician for creative, interesting evaluations and interventions. Many problems are not apparent in bold colors but rather in muted pastels. Often we are aware of an at-risk status, but let it ride because there are other more acute concerns going on with children in infancy and adolescence. Awareness of the consolidation of growth, the coordination of cognitive and other functions and the establishment of self-awareness and self-esteem during this period should help pediatricians focus their efforts on ensuring that the children's physical, cognitive, and psychological foundations are built firmly and maintained solidly. Far from being a period of "latency," school age is a critical era in the development of children, and pediatricians have a responsibility to participate actively in that development.

Effects of theophylline on behavior and learning in children with asthma.

This study examined the potential side effects of theophylline on behavior, attention, memory, and fine motor function in children with asthma. Seventeen children of normal intelligence who were intermittent theophylline users were recruited. Each was not taking medication at the initiation of the study. During the study, each child took the study medication (Theo-Dur tablets, 14 to 16 mg/kg per day or their usual dose, whichever was higher, or placebo) divided every 12 hours for 3 1/2 days (seven doses). A double-blind crossover design was employed such that each subject was randomly assigned to a group receiving theophylline/placebo or placebo/theophylline. After the first period, subjects were tested on a neuropsychological battery designed to assess cognitive performance, while the children, parents, and teachers filled out questionnaires concerning behavior and attention. The same procedure was repeated two weeks later (period 2) under the opposite drug condition. Data were analyzed by means of an analysis of variance, with time (period 1 vs period 2 [performance]) as a repeated measure and medication group as a between-subjects factor. Dependent variables consisted of 27 measures of performance, behavior, and attention. Only one of the 27 analyses revealed a significant group by time interaction. This analysis suggested a significant improvement in memory while taking theophylline; however, a different form of the same test showed no effect. Children and parents also completed a side-effects scale under both drug conditions. When the children were taking theophylline, parents and children noted that the children had more stomachaches and children noted more "shaking hands." The following observations suggest that the failure to find significant behavioral side effects while taking theophylline is not due to the relatively small sample size: (1) Almost all of the analyses fell far short of statistical significance, with findings indicating no trends toward poor performance while taking medication. (2) Correlations between the theophylline level and change in performance clustered around zero, with positive and negative values occurring with about equal frequency. (3) Neither parents nor children could accurately guess the child's medication condition. Thus, although there have been numerous reports on the behavioral side effects of theophylline, such reactions were not revealed in this study.

Iron-EDTA stimulated reduction of indicine N-oxide by the hepatic microsomal fraction, isolated hepatocytes, and the intact rat.

Fe(III) complexes of EDTA and diethylenetriamine pentaacetic acid (DETAPAC) at low concentrations (between 1 and 100 microM) produced up to a 20-fold increase in anaerobic microsomal NADPH- and NADH-dependent reduction of indicine N-oxide. Under aerobic conditions microsomal indicine N-oxide reduction was stimulated to half the levels seen under anaerobic conditions. EDTA alone was much less effective at stimulating indicine N-oxide reduction, while FeCl3 alone had no effect on reduction. Other complexes of Fe(III) had little or no effect in stimulating microsomal indicine N-oxide reduction. Fe(III)-EDTA stimulated indicine N-oxide reduction by purified NADPH-cytochrome P-450 reductase and NADPH. It is probable that iron serves to transfer electrons between microsomal flavoprotein reductases and indicine N-oxide. The redox potential and the presence of an exchangeable ligand, such as water, in the inner ligand sphere of the iron complex are suggested to be important factors in determining which iron complexes will stimulate indicine N-oxide reduction. EDTA complexes of other transition metal ions do not stimulate indicine N-oxide reduction. Hydroxyl radicals, detected as the spin adduct of 5,5-dimethyl-1-pyroline-N-oxide, appear to be formed during Fe(II)-EDTA-dependent reduction of indicine N-oxide under anaerobic conditions. Fe(III)-EDTA at concentrations between 50 and 250 microM stimulated indicine N-oxide reduction by rat isolated hepatocytes up to 5-fold under anaerobic conditions and to half these values under aerobic conditions. By themselves, EDTA and FeCl3 at similar concentrations produced a small stimulation of indicine N-oxide reduction by hepatocytes under anaerobic conditions. Fe(III)-EDTA stimulated indicine N-oxide reduction by murine leukemia P-388 cells under aerobic conditions and by rat caecal flora under anaerobic but not aerobic conditions. Fe(III)-EDTA, EDTA or FeCl3 administered to rats produced a 3-fold increase in the 24-hr urinary excretion of indicine following an i.p. dose of indicine N-oxide.

N-Oxide reduction by hemoglobin, cytochrome C and ferrous ions.

Indicine N-oxide is reduced to indicine by Fe(II) ions, by enzymatically reduced cytochrome c, and by ascorbic acid in conjunction with hemin or cytochrome c. Indicine N-oxide is not reduced by native hemoglobin, but is reduced by denatured hemoglobin. Oxygen competes with indicine N-oxide for reduction by denatured hemoglobin.