Bottled, filtered, and tap water use in Latino and non-Latino children.

OBJECTIVES: To describe bottled, filtered, and tap water consumption and fluoride use among pediatric patients; to analyze differences between ethnic and socioeconomic groups; and to describe the frequency of physician-parent discussions regarding water consumption. DESIGN: Convenience sample survey. SETTING: An urban public health clinic. PARTICIPANTS: Parents attending a public health clinic. OUTCOME MEASURES: The primary outcome measure was the prevalence of tap, filtered, and bottled water use. The secondary outcome measures were supplemental fluoride use and the percentage of patients reporting discussions of water consumption with their physician. RESULTS: A total of 216 parents (80.5% Latino and 19.5% non-Latino) completed the survey. Of the parents, 30.1% never drank tap water and 41.2% never gave it to their children. Latino parents were less likely than non-Latino parents to drink tap water (odds ratio, 0.26; 95% confidence interval, 0.10-0.67) and less likely to give tap water to their children (odds ratio, 0.32; 95% confidence interval, 0.15-0.70). More Latinos believed that tap water would make them sick (odds ratio, 5.63; 95% confidence interval, 2.17-14.54). Approximately 40% of children who never drank tap water were not receiving fluoride supplements. Of the lowest-income families (

Deformational plagiocephaly: development of an objective measure and determination of its prevalence in primary care.

Referrals for deformational plagiocephaly (DP) have increased, but estimates of its actual prevalence vary, depending on the population studied and criteria for diagnosis. Few studies employ an objective technique for diagnosis. The objectives of this study were to validate the Transcranial Diameter Difference (TDD) and, using it, determine the prevalence of DP among infants seen by primary care pediatricians. We determined the TDD of 32 infants referred to a craniofacial clinic for DP; blinded to the TDD a craniofacial surgeon assigned a DP severity score. We compared the TDD and severity scores. The TDD of 192 infants presenting to primary care practices (PCP) were determined and their parents completed a DP risk factor questionnaire. Odds ratios for associations of risk factors with DP were calculated. The correlation between TDD and DP severity score was 0.61 (P = 0.002). All infants whose TDD > 0.6 cm had a severity score > 2; 18.2% of the 192 infants had DP as defined by a TDD > 0.6 cm. Significant odds ratios (95% confidence intervals) for the presence of DP were sleeping supine, 3.5; (1.6, 7.5), and infant head position preference 2.2; (1.0, 4.9). Varying the sleep position decreased the risk of DP, OR = 0.40 (0.2, 0.9). We conclude that the TDD is a valid, objective measure of DP for use in research studies. DP is present in nearly one in five PCP infants. Because an infant who prefers to hold his head in one position is more likely to have DP, advising parents to vary the head position may reduce the risk of DP.

A national perspective of surgery in children with cerebral palsy.

PURPOSE: Children with cerebral palsy (CP) often require surgery, but may be at higher risk for surgical complications and poorer outcomes than children without CP. This study provides a national perspective of the children, hospitals and hospital course associated with the five most commonly performed surgeries in children with CP and compares this perspective to that of children without CP undergoing the same procedures. METHODS: Analysis of the 1997 Healthcare Cost and Utilization Project Kids' Inpatient Database. RESULTS: The most common surgeries performed in children with CP (n = 37 000) were gastrostomy tube placements (n = 1743), soft tissue musculoskeletal procedures (n = 1393), fundoplications (n = 1062), spinal fusions with instrumentation (n = 765) and bony hip surgeries (n = 651). Together, the five procedures accounted for nearly 50 000 hospital days and over 150 million dollars in hospital charges in 1997. The largest difference in outcomes between children with and without CP was seen in those undergoing surgery for scoliosis. CONCLUSIONS: Surgical procedures are frequent in children with CP. Their costs and impact on the US health care system are substantial. The findings provide a strong incentive to carefully study the benefits of the procedures and to develop interventions to improve outcomes, particularly in the case of scoliosis surgery.

In-hospital mortality for children with hypoplastic left heart syndrome after stage I surgical palliation: teaching versus nonteaching hospitals.

OBJECTIVES: Teaching hospitals are perceived to provide a higher quality of care for the treatment of rare disease and complex patients. A substantial proportion of stage I palliation for hypoplastic left heart syndrome (HLHS) may be performed in nonteaching hospitals. This study compares the in-hospital mortality of stage I palliation between teaching and nonteaching hospitals. METHODS: The authors conducted a retrospective cohort study using the Kids' Inpatient Database 1997 and 2000. Patients with HLHS undergoing stage I palliation were identified using International Classification of Diseases, Ninth Revision, Clinical Modification diagnostic and procedural codes. RESULTS: Seven hundred fifty-four and 880 discharges of children with HLHS undergoing stage I palliation in 1997 and 2000, respectively, were identified. The in-hospital mortality for the study population was 28% in 1997 and 24% in 2000. Twenty percent of stage I palliation operations were performed in nonteaching hospitals in 1997. Two percent of operations were performed in nonteaching hospitals in 2000. In 1997 only, in-hospital mortality remained higher in nonteaching hospitals after controlling for stage I palliation hospital volume and condition-severity diagnoses. Low-volume hospitals performing stage I palliation were associated with increased in-hospital mortality in 1997 and 2000. CONCLUSIONS: Patients with HLHS undergoing stage I palliation in nonteaching hospitals experienced increased in-hospital mortality in 1997. A significant reduction in the number of stage I palliation procedures performed in nonteaching hospitals occurred between 1997 and 2000. This centralization of stage I palliation into teaching hospitals, along with advances in postoperative medical and surgical care for these children, was associated with a decrease in mortality. Patients in low-volume hospitals performing stage I palliation continued to experience increased mortality in 2000.

Multiple abnormalities detected by dye reversal genomic microarrays in prostate cancer: a much greater sensitivity than conventional cytogenetics.

Prostate cancer remains the most common male malignancy in Western countries, yet limited information exists regarding genetic changes and clinical correlations. The advent of comparative genomic hybridization microarray (GM) technology has recently allowed for precise screening of DNAs for genetic copy number changes; this offers an advantage over previous techniques, including conventional cytogenetics. A problem with cytogenetic prostate cancer analysis has been the study of the appropriate cell types because this is a highly heterogeneous tumor. We have performed GM using the Spectral Genomics Inc. dye reversal platform on 20 primary prostate tumors. These tumor samples were from frozen tissue collected over the last 10 years and multiple clinical parameters, including follow-up were collected on these patients; cytogenetic analysis was previously attempted on all patients. Eighty percent (16/20) of specimens showed copy number changes, 65% of which were losses and 35% were gains of genetic material. The most common changes observed were loss of an interstitial region of 2q (8 cases, 40%), followed by loss of interstitial 6q (6 cases, 30%), loss at 8p and 13q (5 cases each, 25%), gain at 3p and loss at 5q, 16q, and Xq (4 cases each, 20%), and gain at 8p (3 cases, 15%). There was evidence of correlation of loss at 5q with a positive node status. Cytogenetic studies on these same patients only detected clonal changes in 40% (8/20) specimens and did not detect the majority of abnormalities seen by the GM technique. We propose this technology for the evaluation of prostate and other heterogeneous cancers as a rapid and efficient way to detect genetic copy number changes.

Serious bacterial infections in febrile infants 1 to 90 days old with and without viral infections.

OBJECTIVE: The risk of serious bacterial infection (SBI) in febrile infants who are classified as low risk (LR) or high risk (HR) by the Rochester criteria has been established. LR infants average a 1.4% occurrence of SBI, whereas HR infants have an occurrence of 21%. The occurrence of SBI in Rochester LR or HR infants with confirmed viral infections is unknown. The objective of this study was to determine the occurrence of SBI in Rochester LR and HR infants with and without viral infections. METHODS: All febrile infants who were 90 days or younger and evaluated at Primary Children's Medical Center between December 1996 and June 2002 were eligible. Infants were classified as Rochester LR or HR, and discharge diagnoses were collected. Viral testing for enteroviruses, respiratory viruses, rotavirus, and herpesvirus was performed as indicated by study protocol, clinical presentation, and season of the year. Results of all bacterial cultures were reviewed. RESULTS: Of 1779 infants enrolled, 1385 (78%) had some form of viral diagnostic testing and 491 (35%) had 1 or more viruses identified. By the Rochester criteria, 456 (33%) infants were classified as LR and 922 (67%) infants as HR. For infants with viral infections, the occurrence of SBI was significantly lower than in infants without a viral infection (4.2% vs 12.3%). Rochester HR virus-positive (HR+) infants had significantly fewer bacterial infections than HR virus-negative (HR-) infants (5.5% vs 16.7%). When compared with HR- infants, HR+ infants were less likely to have bacteremia, urinary tract infection, or soft tissue infections, and HR+ infants had a similar occurrence of bacteremia as LR infants (0.92% vs 1.97%). CONCLUSIONS: Febrile infants with confirmed viral infections are at lower risk for SBI than those in whom a viral infection is not identified. Viral diagnostic data can positively contribute to the management of febrile infants, especially those who are classified as HR.

National estimates of hospital utilization by children with gastrointestinal disorders: analysis of the 1997 kids' inpatient database.

OBJECTIVES: To identify and to generate national estimates of the principal gastrointestinal (GI) diagnoses associated with hospital utilization and to describe national hospital utilization patterns associated with pediatric GI disorders. STUDY DESIGN: We analyzed a nationwide and stratified probability sample of 1.9 million hospital discharges from 1997 of children 18 years and younger, weighted to 6.7 million discharges nationally. Principal GI diagnoses were identified through the use of the Clinical Classification Software and Major Diagnostic Categories. RESULTS: In 1997 in the United States, there were 329,825 pediatric discharges associated with a principal GI diagnosis, accounting for more than 2.6 billion US dollars in hospital charges and more than 1.1 million hospital days. Appendicitis, intestinal infection, noninfectious gastroenteritis, abdominal pain, esophageal disorders, and digestive congenital anomalies combined accounted for 75.1% of GI discharge diagnoses, 64.2% of GI hospital charges, and 68.0% of GI hospital days. Excluding normal newborn infants and conditions related to pregnancy, GI disorders were the third leading cause of hospitalization. CONCLUSIONS: GI disorders are a leading cause of hospitalization of children. A minority of GI conditions account for the majority of measures of utilization. Children are hospitalized for GI conditions and at institutions that are distinct from adults.

Real-time PCR quantification of AT1 and AT2 angiotensin receptor mRNA expression in the developing rat kidney.

BACKGROUND/AIMS: Angiotensin II (Ang II) is an important growth factor in the fetal kidney. Molecular cloning and pharmacological studies have defined two major classes of Ang II receptors designated AT1 and AT2. Two AT1 isoforms, AT1A and AT1B, exist in rodents. AT1 promotes growth and proliferation and mediates many of the known physiological actions of Ang II. AT2 appears to antagonize AT1. Our goal was to measure their relative contributions to Ang II signaling in the developing kidney. METHODS: We used real-time RT-PCR to quantify AT1A, AT1B, AT2 and the housekeeping gene EF1alpha mRNA in kidneys from embryonic (E) day 14-20 and postnatal (P) day 1-14 rats. RESULTS: AT2 mRNA declined from 1.4 x 10(4) copies/10(6) copies EF1alpha on E14 to 4.2 x 10(3) copies/10(6) copies EF1alpha on P14. In contrast, total AT1 mRNA increased gradually from 2.0 x 10(3) copies/10(6) copies EF1alpha on E14 to 2.0 x 10(4) copies/10(6) copies EF1alpha on P14, with AT1A accounting for about 90% of total AT1 mRNA throughout nephrogenesis. Moreover, the ratio of AT2/(AT1A + AT1B) decreased in a log-linear fashion during maturation, from 6.7 on E14 to 0.2 on P14. CONCLUSION: The ratio of AT2 to AT1 gene expression modulates Ang II action in the developing kidney.

Predictors of repeat pregnancy in a program for pregnant teens.

STUDY OBJECTIVE: To describe repeat pregnancy among adolescents and to compare those who experienced a repeat pregnancy to those who did not. DESIGN, SETTING, PARTICIPANTS: Retrospective case control of all adolescents who entered and exited the Teen Mother & Child Program, a multidisciplinary clinic for pregnant and parenting teens and their children, between 1985 and 2000. MAIN OUTCOME MEASURE: Repeat pregnancy. RESULTS: Over the 16-yr study period, 1838 teens entered and exited the program with the mean time in the program of 1.9 yrs. 194 (10.6%) teens went on to have a second pregnancy, and 4 of those had a third pregnancy. Ninety-two percent (n=175) of these pregnancies resulted in a live birth. The mean interval between delivery of the initial child and delivery of the second child was 21.8 months (range 5.4-53.2). Teens repeating (R) were compared to those who did not repeat (NR). R were younger at entry and older at exit from the program (both P<0.0001). R were more likely to be Hispanic (P=0.009) or have a partner who was Hispanic (P=0.02). R were more likely to have experienced a poor initial pregnancy outcome (miscarriage, stillbirth) (P=0.03). R were more likely than NR to be in a stable relationships with the father of the baby (i.e., married or engaged) (P=0.03). Self-report of physical and sexual abuse, depression, and substance abuse were common, but did not differ between R and NR. However, R were more likely than NR to self-report suicide gestures/attempts and to have a significant psychiatric history (P=0.01, P=0.004). Only 24% of R and 26% of NR had completed high school by the time of exit from the program. CONCLUSIONS: Ten percent of adolescents served by comprehensive multidisciplinary teen pregnancy program experienced a repeat pregnancy while in the program. Compared to nonrepeaters, adolescents who experienced a repeat pregnancy were younger, were more frequently Hispanic, and were more likely to be in a stable relationship with the baby's father. Many of the program's clients have psychosocial factors reported in the literature to be associated with repeat pregnancy. A history of suicide gestures/attempts and a significant psychiatric history were more common in those who had a repeat pregnancy. Disappointingly, only about 25% of the adolescents completed high school by the time they exited the program whether they experienced a repeat pregnancy or not. Although directing interventions (e.g., mental health services, counseling those who miscarried) to teens who appear to be at highest risk for a repeat pregnancy may decrease their risk of repeating, all teens in our program would likely benefit from such services.

Intrathecal baclofen therapy in children with cerebral palsy: efficacy and complications.

OBJECTIVES: To describe the efficacy of intrathecal baclofen (ITB) therapy in the management of spasticity in young children with cerebral palsy (CP) and to identify risk factors for complications. DESIGN: Consecutive case series of 25 implanted ITB delivery systems during a 48-month period. SETTING: Pediatric specialty hospital and outpatient department. PARTICIPANTS: Twenty-three children (age range, 4.5-17.4y) with CP (spastic diplegia in 22%; spastic quadriplegia in 61%; mixed-type diplegia in 4%; mixed-type quadriplegia in 13%). INTERVENTION: Intrathecal baclofen therapy in children with cerebral palsy. MAIN OUTCOME MEASURES: Ashworth Scale scores before treatment and at 6 and 12 months after ITB therapy; frequency and nature of complications; and relation between patient characteristics and outcomes. RESULTS: Average Ashworth scores +/- standard deviation decreased from 3.26+/-.73 to 2.34+/-.83 (P

Associations between maternal and fetal serum levels of immune activation markers and fetal growth.

During pregnancy, signs of maternal immunologic sensitization to fetal HLA and other fetoplacental alloantigens are often detectable in peripheral blood. Presumbly, this in part reflects immune activity at the maternal-fetal interface. This response may involve activation of maternal T cells, which stimulate placental growth via lymphokine production. To shed light on this mechanism, data on placental weight, neonatal anthropometry, gestational age, fetomaternal HLA relationships (reflecting a potential for HLA allosensitization), and serum levels of three immune activation markers in maternal and cord blood were collected in a sample of 61 primiparous women and their neonates. The activation markers were soluble CD8 antigen (sCD8), interleukin-2 receptor (sIL-2R), and beta-2 microglobulin (ß2 m). Mean fetal and maternal sCD8 and ß2 m levels, and mean fetal sIL-2R levels were significantly higher than published norms. Fetal means for all three markers exceeded maternal means, and both sIL-2R and ß2 m were highly correlated between mother and fetus. This suggests that fetal sIL-2R and ß2 m levels result in part from transport or diffusion from the maternal compartment. No associations were found between fetomaternal HLA relationships, activation markers, and placental weight. The difference between the fetal and maternal ß2 m value was significantly correlated with birth weight, controlling for chest circumference and crown-heel length. Associations between birth weight and fetomaternal HLA relationships could not be interpreted with certainty. These findings suggest that maternal immune activation and diffusion or transport of ß2 m into fetal compartment enhances fetal growth in fat-free body mass. © 1995 Wiley-Liss, Inc.

Lymphocyte alloantigenic challenge as a potential cofactor in HIV infection and progression to AIDS.

A hypothesis is developed that circulatory exposure to alloantigens found on lymphocytes triggers a series of events leading to suppression of the cell-mediated arm of the immune system and, therefore, that such alloantigenic challenge can be an important cofactor promoting infection with the human immunodeficiency virus (HIV) and development of the acquired immunodeficiency syndrome (AIDS) following infection. The explanatory model that is developed is based in large part on current knowledge of the results of fetal lymphocyte alloantigenic challenge of the maternal immune system. It is our contention that the maternal response which leads to suppression of cell-mediated immunity is a mechanism promoting survival of the fetal "allograft," and that this mechanism is an evolutionary adaptation in humans and other placental mammals. We also hypothesize that circulatory exposure to these same alloantigens leads to an immunosuppressive state which enhances survival of HIV in an exposed individual and augments the immunosuppressive action of HIV in promoting progression to clinical AIDS. Findings from studies of individuals who are at risk for exposure to lymphocyte alloantigenic challenge and from HIV infected patients are reviewed and discussed in light of this hypothesis.