Repatriation of a historical North Atlantic right whale habitat during an era of rapid climate change.

Climate change is affecting species distributions in space and time. In the Gulf of Maine, one of the fastest-warming marine regions on Earth, rapid warming has caused prey-related changes in the distribution of the critically endangered North Atlantic right whale (Eubalaena glacialis). Concurrently, right whales have returned to historically important areas such as southern New England shelf waters, an area known to have been a whaling ground. We compared aerial survey data from two time periods (2013-2015; 2017-2019) to assess trends in right whale abundance in the region during winter and spring. Using distance sampling techniques, we chose a hazard rate key function to model right whale detections and used seasonal encounter rates to estimate abundance. The mean log of abundance increased by 1.40 annually between 2013 and 2019 (p = 0.004), and the mean number of individuals detected per year increased by 2.23 annually between 2013 and 2019 (R2 = 0.69, p = 0.001). These results demonstrate the current importance of this habitat and suggest that management options must continually evolve as right whales repatriate historical habitats and potentially expand to new habitats as they adapt to climate change.

Characterization of large basking shark Cetorhinus maximus aggregations in the western North Atlantic Ocean.

Cetorhinus maximus aggregations recorded during extensive aerial survey efforts off the north-eastern United States between 1980 and 2013 included aggregations centring on sightings with group sizes of at least 30 individuals. These aggregations occurred in summer and autumn months and included aggregation sizes of up to 1398 individuals, the largest aggregation ever reported for this species. The aggregations were associated with sea surface temperatures of 13-24° C and chlorophyll-a concentrations of 0·4-2·6 mg m-3 and during one aggregation, a high abundance of zooplankton prey was present. Photogrammetric tools allowed for the estimation of total body lengths ranging between 4 and 8 m. Characterization of these events provides new insight into the potential biological function of large aggregations in this species.

Severe nutritional deficiencies in toddlers resulting from health food milk alternatives.

It is widely appreciated that health food beverages are not appropriate for infants. Because of continued growth, children beyond infancy remain susceptible to nutritional disorders. We report on 2 cases of severe nutritional deficiency caused by consumption of health food beverages. In both cases, the parents were well-educated, appeared conscientious, and their children received regular medical care. Diagnoses were delayed by a low index of suspicion. In addition, nutritional deficiencies are uncommon in the United States and as a result, US physicians may be unfamiliar with their clinical features. Case 1, a 22-month-old male child, was admitted with severe kwashiorkor. He was breastfed until 13 months of age. Because of a history of chronic eczema and perceived milk intolerance, he was started on a rice beverage after weaning. On average, he consumed 1.5 L of this drink daily. Intake of solid foods was very poor. As this rice beverage, which was fallaciously referred to as rice milk, is extremely low in protein content, the resulting daily protein intake of 0.3 g/kg/day was only 25% of the recommended dietary allowance. In contrast, caloric intake was 72% of the recommended energy intake, so the dietary protein to energy ratio was very low. A photograph of the patient after admission illustrates the typical features of kwashiorkor: generalized edema, hyperpigmented and hypopigmented skin lesions, abdominal distention, irritability, and thin, sparse hair. Because of fluid retention, the weight was on the 10th percentile and he had a rotund sugar baby appearance. Laboratory evaluation was remarkable for a serum albumin of 1.0 g/dL (10 g/L), urea nitrogen <0.5 mg/dL (<0.2 mmol/L), and a normocytic anemia with marked anisocytosis. Evaluation for other causes of hypoalbuminemia was negative. Therapy for kwashiorkor was instituted, including gradual refeeding, initially via a nasogastric tube because of severe anorexia. Supplements of potassium, phosphorus, multivitamins, zinc, and folic acid were provided. The patient responded dramatically to refeeding with a rising serum albumin and total resolution of the edema within 3 weeks. At follow-up 1 year later he continued to do well on a regular diet supplemented with a milk-based pediatric nutritional supplement. The mortality of kwashiorkor remains high, because of complications such as infection (kwashiorkor impairs cellular immune defenses) and electrolyte imbalances with ongoing diarrhea. Children in industrialized countries have developed kwashiorkor resulting from the use of a nondairy creamer as a milk alternative, but we were unable to find previous reports of kwashiorkor caused by a health food milk alternative. We suspect that cases have been overlooked. Case 2, a 17-month-old black male, was diagnosed with rickets. He was full-term at birth and was breastfed until 10 months of age, when he was weaned to a soy health food beverage, which was not fortified with vitamin D or calcium. Intake of solid foods was good, but included no animal products. Total daily caloric intake was 114% of the recommended dietary allowance. Dietary vitamin D intake was essentially absent because of the lack of vitamin D-fortified milk. The patient lived in a sunny, warm climate, but because of parental career demands, he had limited sun exposure. His dark complexion further reduced ultraviolet light-induced endogenous skin synthesis of vitamin D. The patient grew and developed normally until after his 9-month check-up, when he had an almost complete growth arrest of both height and weight. The parents reported regression in gross motor milestones. On admission the patient was unable to crawl or roll over. He could maintain a sitting position precariously when so placed. Conversely, his language, fine motor-adaptive, and personal-social skills were well-preserved. Generalized hypotonia, weakness, and decreased muscle bulk were present. Clinical features of rickets present on examination included: frontal bossing, an obvious rachitic rosary (photographed), genu varus, flaring of the wrists, and lumbar kyphoscoliosis. The serum alkaline phosphatase was markedly elevated (1879 U/L), phosphorus was low (1.7 mg/dL), and calcium was low normal (8.9 mg/dL). The 25-hydroxy-vitamin D level was low (7.7 pg/mL) and the parathyroid hormone level was markedly elevated (114 pg/mL). The published radiographs are diagnostic of advanced rickets, showing diffuse osteopenia, frayed metaphyses, widened epiphyseal plates, and a pathologic fracture of the ulna. The patient was treated with ergocalciferol and calcium supplements. The published growth chart demonstrates the dramatic response to therapy. Gross motor milestones were fully regained within 6 months. The prominent neuromuscular manifestations shown by this patient serve as a reminder that rickets should be considered in the differential diagnosis of motor delay. (ABSTRACT TRUNCATED)

Evaluation of covert video surveillance in the diagnosis of munchausen syndrome by proxy: lessons from 41 cases.

OBJECTIVE: In 1993, Children's Healthcare of Atlanta at Scottish Rite (formery Scottish Rite Children's Medical Center, Atlanta, GA) added facilities to perform inpatient covert video surveillance (CVS) of suspected cases of Munchausen syndrome by proxy (MSBP). Forty-one patients were monitored from 1993 to 1997. This study was performed to review our experience with these cases. How useful was video surveillance in making the diagnosis? What were the characteristics of families with children who were victims of MSBP? METHODOLOGY: Medical, social work, security, and administrative records of all children who underwent covert video monitoring at Children's Healthcare of Atlanta at Scottish Rite from 1993 through 1997 were reviewed retrospectively by a team of physicians, risk managers, and social workers. RESULTS: A diagnosis of MSBP was made in 23 of 41 patients monitored. CVS was required to make the diagnosis in 13 (56.1%) of these 23, and supportive of the diagnosis in 5 (21.7%) cases. In 4 patients, this surveillance was instrumental in establishing innocence of the parents. MSBP was more common in Caucasian patients than in other ethnic groups seen at our hospital. Fifty-five percent of mothers gave a history of health care work or study, and another 25% had previously worked in day care. Although many of caretakers fit the profile of MSBP, such as excessive familiarity with medical staff, eagerness for invasive medical testing, and history of health care work, these characteristics were not sensitive indicators of MSBP in our study. Even when present, they were not sufficiently compelling to make the diagnosis. CONCLUSIONS: CVS is required to make a definitive and timely diagnosis in most cases of MSBP. Without this medical diagnostic tool, many cases will go undetected, placing children at risk. All tertiary care children's hospitals should develop facilities to perform CVS in suspected cases.

Absence of serum chemistry abnormalities in pediatric patients presenting with seizures.

To determine the utility of the routine practice of obtaining serum chemistry values on children presenting after a seizure, we reviewed the emergency department records of 241 episodes of seizures in pediatric patients. One hundred fifty-five nonfebrile (49 initial, 106 recurrent) and 86 febrile (53 initial, 33 recurrent) convulsive episodes were analyzed. At least one serum chemistry value was obtained in 149 (64%) patients. Clinically significant abnormalities were found in 0/149 serum sodium, 0/148 glucose and blood urea nitrogen, 0/86 calcium, and 0/61 magnesium studies. We concluded that routine determination of serum chemistry values in pediatric patients presenting with a seizure is unnecessary unless specific clinical data strongly suggest otherwise.

Distal renal tubular acidosis as the initial manifestation of systemic lupus erythematosus in an adolescent.

Distal renal tubular acidosis (dRTA) as the initial manifestation of systemic lupus erythematosus (SLE) has not been described previously. We report a 14-year-old female adolescent, first presenting with findings consistent with dRTA, whose renal biopsy demonstrated immune mesangial deposits consistent with lupus nephritis. Seven months later, she developed classic extrarenal manifestations of SLE. We recommend that adolescents with dRTA be evaluated and followed closely for the possibility of SLE.

Can residents be trained to counsel patients about quitting smoking? Results from a randomized trial.

STUDY OBJECTIVE: To evaluate the effectiveness of two teaching interventions to increase residents' performance of smoking cessation counseling. DESIGN: Randomized controlled factorial trial. SETTING: Eleven residency programs, in internal medicine (six), family medicine (three), and pediatrics (two). Programs were located in three university medical centers and four university-affiliated community hospitals. PARTICIPANTS: 261 residents who saw ambulatory care patients at least one half-day per week, and 937 returning patients aged 17 to 75 years who reported having smoked five or more cigarettes in the preceding seven days. Of the 937, 843 were eligible for follow-up, and 659 (78%) were interviewed by phone at six months. INTERVENTIONS: Two interventions (tutorial and prompt) and four groups. The tutorial was a two-hour educational program in minimal-contact smoking cessation counseling for residents. The prompt was a chart-based reminder to assist physician counseling. One group of residents received the tutorial; one, the prompt; and one, both. A fourth group received no intervention. MEASUREMENT AND RESULTS: Six months after the intervention, physician self-reports showed that residents in the tutorial + prompt and tutorial-only groups had used more counseling techniques (1.5-1.9) than had prompt-only or control residents (0.9). Residents in all three intervention groups advised more patients to quit smoking (76-79%) than did control group residents (69%). The tutorial had more effect on counseling practices than did the prompt. Physician confidence, perceived preparedness, and perceived success followed similar patterns. Exit interviews with 937 patients corroborated physician self-reports of counseling practices. Six months later, self-reported and biochemically verified patient quitting rates for residents in the three intervention groups (self-reported: 5.3-8.2%; biochemically verified: 3.4-5.7%) were higher than those for residents in the control group (self-reported: 5.2%; biochemically verified: 1.7%), though the differences were not statistically significant. CONCLUSION: A simple and feasible educational intervention can increase residents' smoking cessation counseling.

Smoking cessation counseling by resident physicians in internal medicine, family practice, and pediatrics.

Residents in primary care specialties care for many patients who smoke cigarettes, but little is known about their smoking cessation counseling (SCC). We surveyed 309 residents (72 family practice, 171 internal medicine, and 66 pediatrics residents) in 13 programs to determine their practices, knowledge, attitudes, and training in SCC. More than 90% thought physicians are responsible for SCC, the majority routinely took smoking histories, and 80% attempted to motivate patients to quit smoking. However, 25% or fewer reported discussing obstacles to quitting, setting a quit date, prescribing nicotine gum, scheduling follow-up visits, or providing self-help materials. Family practice residents used more SCC techniques (1.8) than did internal medicine (0.8) and pediatrics (0.1) residents. Only 54% of residents reported recent SCC training and 13% reported formal SCC training. Recent training correlated with the number of counseling techniques used. Residents in primary care specialties report positive attitudes but inadequate practice and training in SCC.

Adolescent males who insert genitourinary foreign bodies: is psychiatric referral required?

Although much is known about the urologic aspects of genitourinary foreign bodies, the psychiatric profile of the adolescent male who inserts a foreign body into his urethra is not available. Six cases from a urologic service are presented, and the pertinent literature is reviewed. Psychiatric consultation for such selfinserters will allow the development of such a profile. An appropriate management plan can then be formulated.

Supernumerary nipples and renal anomalies in neonates.

A high rate of association between supernumerary nipples (SNNs) and hidden renal anomalies has previously been reported. We examined 2035 term infants and detected SNNs in 49. Only one patient, at age 4 months, was found to have a renal anomaly, as determined by ultrasound examination. The likelihood of finding a renal anomaly in a term infant with an SNN is likely to be lower than previously reported.

Achalasia in an adolescent with behavioral features compatible with anorexia nervosa.

A case report of an adolescent female with esophageal achalasia and behavioral features of anorexia nervosa is presented. This unusual combination of problems may cause similar physical symptoms and thus create diagnostic confusion.