Thursday, October 26, 2006

HIV in Estonia

High HIV prevalence among injecting drug users in Estonia: implications for understanding the risk environment

Platt, Lucy a; Bobrova, Natalia b; Rhodes, Tim a; Uuskula, Anneli c; Parry, John V d; Ruutel, Kristi e; Talu, Ave e; Abel, Katri e; Rajaleid, Kristiina c; Judd, Ali f

AIDS. 20(16):2120-2123, October 24, 2006.

We found a high prevalence of HIV among injecting drug users (IDU) 54% in Tallinn and 90% in Kohtla Jarve, Estonia. Risk factors for HIV in Tallinn included use of the drug 'china white', being registered as an IDU at a drug treatment clinic, and sharing injecting equipment with sex partners. Differences existed in risk behaviour between the cities. An urgent scale-up of HIV prevention is needed. It is also important to explore how local 'risk environments' mediate the risk of HIV transmission.

(C) 2006 Lippincott Williams & Wilkins, Inc.

Music therapy of autism

Music therapy in the assessment and treatment of autistic spectrum disorder: clinical application and research evidence

T. Wigram and C. Gold

Child: Care, Health and Development
Volume 32 Page 535

Background. Children and adolescents with autistic spectrum disorder (ASD) presenting with significant limitations in conventional forms of verbal and non-verbal communication are found to respond positively to music therapy intervention involving both active, improvizational methods and receptive music therapy approaches. Improvizational musical activity with therapeutic objectives and outcomes has been found to facilitate motivation, communication skills and social interaction, as well as sustaining and developing attention. The structure and predictability found in music assist in reciprocal interaction, from which tolerance, flexibility and social engagement to build relationships emerge, relying on a systematic approach to promote appropriate and meaningful interpersonal responses.
Results. Published reports of the value and effectiveness of music therapy as an intervention for children with ASD range from controlled studies to clinical case reports. Further documentation has emphasized the role music therapy plays in diagnostic and clinical assessment. Music therapy assessment can identify limitations and weaknesses in children, as well as strengths and potentials. Research evidence from a systematic review found two randomized controlled trials that examined short-term effects of structured music therapy intervention. Significant effects were found in these studies even with extremely small samples, and the findings are important because they demonstrate the potential of the medium of music for autistic children. Case series studies were identified that examined the effects of improvizational music therapy where communicative behaviour, language development, emotional responsiveness, attention span and behavioural control improved over the course of an intervention of improvizational music therapy.

Tuesday, October 24, 2006

Pediatric malignancies

The challenge of nephroblastoma in a developing country

SO Ekenze, NEN Agugua-Obianyo and OA Odetunde
Sub-Department of Paediatric Surgery, University of Nigeria Teaching Hospital, Enugu, Nigeria

Background: Advances in paediatric oncology has tremendously improved the outcome in children with nephroblastoma. In most developing countries, however, the survival rate is still very low.
Objective: To study the outcome and the impediments to the management of nephroblastoma in Southeast Nigeria.
Methods: Analysis of 42 children managed for nephroblastoma over a 10-year period (January 1995–December 2004) at the University of Nigeria Teaching Hospital, Enugu, Nigeria is made. Diagnosis was based on clinical, radiologic and histologic evaluation.
Results: The peak age incidence was 2–5 years with a male:female ratio of 1.1:1. Abdominal mass was the main presentation in all the children. Treatment consisted of nephroureterectomy followed by adjuvant chemotherapy with Vincristine, Actinomycin D and Cyclophosphamide. Adriamycin was added for metastatic disease. Twenty-two children (52.3%) had stage III disease, 13 (31.0%) had stage IV, while the remaining seven (16.7%) children had stage II. Stage I disease was not encountered. Seven children had inoperable tumor requiring pre-operative chemotherapy. While 25 children were available for evaluation, 17 were lost to follow up. Four children died of complications of treatment, while 11 relapsed with poor outcome. With a mean follow up of 21 months, the 5-year survival rate is 40%.
Conclusion: Morbidity and mortality with nephroblastoma is high in our environment. Late presentation, poverty, ignorance and poor compliance to treatment constitute a great challenge to the paediatric oncologist in a developing country. Solutions may lie in improving health funding and health information in the health care delivery system. Free health care for children with malignancy is advocated. Collaboration with institutions in the privileged parts of the world may help.
Key words: nephroblastoma, challenges, late presentation

Annals of Oncology 2006 17(10):1598-1600
© 2006 European Society for Medical Oncology


Leukemia does not live by 1 lesion alone

Judith E. Karp

Leukemias are characterized by dysregulation of proliferation, differentiation, and the balance between cell life and death, with that balance shifted toward survival even in the face of major cellular stress. Such survival likely relates, at least in part, to activation of multiple interactive pathways rather than a single molecular lesion, with the result being a "cascade" of molecular activations that converge on central determinants of overall cellular survival.

The current study demonstrates that activation of 1 or more pathways are linked to a poor clinical prognosis in terms of achievement of complete remission, duration of remission, and overall survival. Indeed, in this large group of patients, there appears to be a "dose response," with clinical outcome inversely related to the number of pathways activated. The additional finding of an "all-or-none" phenomenon, with activation of either none or all 3 pathways being the more common patterns, implies that at least for the "stimulated" populations, there may be an operative trigger or amplification mechanism in cells, such as contact between leukemic cells and bone marrow stroma. Not surprisingly, however, these findings are not universal, since certain molecular lesions, notably FLT3–internal tandem duplication (ITD), do not appear to be associated with activation of the particular pathways examined in this study.

All of these findings are important because malignant cell survival depends on multiple interactive pathways that can be sustained by diverse intermediaries and, if 1 path is blocked, another can step up to maintain the cell's drive to survive. This compensatory ability suggests that the use of single "targeted" agents may well be suboptimal—a concept that, unfortunately, is all too well supported by clinical experience in all malignancies and has broad implications for the entire field of cancer therapeutics. We need to listen carefully to the authors' eloquent plea for a new paradigm in drug development, namely the testing of multiple investigational agents in ways that target complementary molecules and attack the malignant phenotype from multiple angles.

Blood, 1 October 2006, Vol. 108, No. 7, pp. 2133-2134.

Sunday, October 22, 2006

Women's Health

Epilepsy in women

American Family Physician; Kansas City; Oct 15, 2002; Martha J Morrell;

Abstract: Epilepsy in women raises special reproductive and general health concerns. Seizure frequency and severity may change at puberty, over the menstrual cycle, with pregnancy, and at menopause. Estrogen is known to increase the risk of seizures, while progesterone has an inhibitory effect. Many antiepileptic drugs induce liver enzymes and decrease oral contraceptive efficacy. Women with epilepsy also have lower fertility rates and are more likely to have anovulatory menstrual cycles, polycystic ovaries, and sexual dysfunction. Irregular menstrual cycles, hirsutism, acne, and obesity should prompt an evaluation for reproductive dysfunction. Children who are born to women with epilepsy are at greater risk of birth defects, in part related to maternal use of antiepileptic drugs. This risk is reduced by using a single antiepileptic drug at the lowest effective dose and by providing preconceptional folic acid supplementation. Breastfeeding is generally thought to be safe for women using antiepileptic medications.

Epilepsy in Women (PDF 744KB)

The diagnosis of child abuse in severely injured infants

Variation in the diagnosis of child abuse in severely injured infants

Trokel M, Wadimmba A, Griffith J, Sege R.
Department of Pediatrics, Boston Medical Center, Boston, Massachusetts, USA.

OBJECTIVE: Diagnosis of child abuse is difficult and may reflect patient, practitioner, and system factors. Previous studies have demonstrated potential lethal consequences if cases of abuse are missed and suggested a role for continuing medical education in improving the accuracy of diagnosis of suspected abuse. Although the majority of injured American children are treated at general hospitals, most published studies of severe injury resulting from child abuse have been conducted at children's hospitals. The objective of this study was to evaluate the role of hospital type in observed variations in the frequency of diagnosis of child physical abuse among children with high-risk injuries. METHODS: Hospital discharge data were evaluated, and adjusted rates of abuse diagnosis were reported according to hospital type. A regression model estimated the number of cases of abuse that would have been diagnosed if all hospitals identified abuse as frequently as observed at pediatric specialty hospitals. This study consisted of children who were <1 year old and admitted to US hospitals in 1997 for treatment of traumatic brain injury or femur fracture, excluding penetrating trauma or motor-vehicle-related injury. A total of 2253 weighted cases were analyzed. RESULTS: The proportion of patients with a medical diagnosis of child abuse varied widely between hospital types: 29% of the cases were diagnosed as abuse at children's hospitals compared with 13% at general hospitals. An estimated 178 infants (39% of total) with these specific injuries would have been identified as abused had they been treated at children's rather than general hospitals. CONCLUSIONS: Hospital type was associated with large variations in the frequency of diagnosis of child abuse. This variation was not related to observed differences in the patients or their injuries and may result from systematic underdiagnosis in general hospitals. This result has implications for quality-improvement programs at general hospitals, where the majority of injured children in the United States receive emergent medical care.

acute lymphoblastic leukemia

Dendritic cell deficiencies in pediatric acute lymphoblastic leukemia patients

Maecker B, Mougiakakos D, Zimmermann M, Behrens M, Hollander S, Schrauder A, Schrappe M, Welte K, Klein C.
Department of Pediatric Hematology/Oncology, Hannover Medical School, Hannover, Germany.

Acute lymphoblastic leukemia (ALL) cells are particularly poor at generating anti-leukemia immunity, despite residing in lymphoid organs. To assess a potential role of dendritic cells (DC) in poor anti-leukemia immunity, we analyzed peripheral blood DC in 55 pediatric ALL patients at the time of initial diagnosis and 19 age-matched healthy controls. Dendritic cells were identified by their expression of HLA-DR, lack of B, T, NK, and monocyte markers, and expression of CD11c (myeloid DC(mDC)) or BDCA-2 (plasmacytoid DC(pDC)) using flow cytometry. We found that in children with B-lineage ALL, numbers of both mDC and pDC were significantly reduced (P=0.0001). In contrast, T-lineage ALL patients showed normal pDC and significantly elevated mDC (P=0.003) levels, with normal expression of HLA-DR and co-stimulatory molecules. A decrease in DC could not be explained by general impairment of myelopoiesis, as we could not demonstrate a correlation of DC numbers with granulocyte/monocyte numbers in patients with B-lineage ALL. However, aberrant expression of myeloid surface markers on leukemic blasts was frequent in patients lacking myeloid DC indicating a potential block of DC differentiation. Thus, depletion of DC in B-lineage ALL patients may contribute to poor anti-leukemia immune responses.

Leukemia. 2006 Feb 23

Saturday, October 21, 2006

Pediatric Conference

Pediatric News: Conference Calendar

XXX Panamerican Congress of Gastroenterology (GASTRO CANCUN 2006)
November 11 2006 - November 16 2006

3rd International POSNA/AAOS Pediatric Orthopaedic Symposium # 3019
November 29 2006 - December 03 2006

Emergencies and Procedures in Pediatrics
December 01 2006 - December 03 2006

Review and Update of Pediatric Emergency Medicine (CME)
January 22 2007 - January 26 2007

Pediatric Emergency Medicine: A Review and Update (CME)
February 26 2007 - March 02 2007

Neurology for the Non-Neurologist (CME)
March 19 2007 - March 23 2007

Depression in Children

Psychological Correlates of Depression in Children with Recurrent Abdominal Pain

Laura Kaminsky, PhD1, Marli Robertson, MD2 and Deborah Dewey, PhD2
1) Department of Psychology, University of Calgary, and 2) Department of Paediatrics, University of Calgary

Objective To examine the associations between coping style, social support, self-efficacy, locus of control, maternal adjustment, and depressive symptoms in children with recurrent abdominal pain (RAP) of childhood. Methods Fifty children with RAP (8–18 years) and their mothers were recruited from a gastroenterology clinic (GI) and community medical practices. Participants completed questionnaires that assessed coping style, social support, self-efficacy, locus of control, maternal adjustment, and psychological adjustment. Results Passive coping strategies such as isolating oneself from others, catastrophizing, and behavioral disengagement were associated with more child-reported depressive symptoms. Higher levels of self-efficacy and greater social support from teachers and classmates were associated with fewer child-reported depressive symptoms. Higher levels of maternal adjustment problems, higher social support from parents, and lower social support from classmates were associated with maternal reports of more child internalizing symptoms. Conclusions These findings suggest that coping style, self-efficacy, social support, and maternal adjustment are correlates of depressive symptoms in children with RAP.

Journal of Pediatric Psychology 2006 Volume 31, Number 9: 956-966

Friday, October 20, 2006

American Dietetic Association

Body Mass Index, Sex, Interview Protocol, and Children’s Accuracy for Reporting Kilocalories Observed Eaten at School Meals

Suzanne Domel Baxter, PhD, RD, FADA, Albert F. Smith, PhD, MS, Mark S. Litaker, PhD1, Caroline H. Guinn, RD1, Michele D. Nichols, MS, Patricia H. Miller, PhD, Katherine Kipp, PhD

Journal of the American Dietetic Association Volume 106, Issue 10, Pages 1656-1662 (October 2006)

This pilot study investigated body mass index (BMI; calculated as kg/m2), sex, interview protocol, and children’s accuracy for reporting kilocalories. Forty 4th-grade children (20 low-BMI: ≥5th and <50th>

© 2006 American Dietetic Association. Published by Elsevier Inc. All rights reserved.

XIX World Congress

XIX World Congress of ISHR

XIX World Congress
Visit the official website World Congress - Italy 2007

The Concept
To organise a congress based on a unique scientific program in a unique environment. The program will range “from cell to man to society”. We believe that in 2007, with the complete availability of the genome information, it will be essential not only to link basic with clinical science, but also to consider the influence of cardiovascular research on lifestyle and the environment and vice versa.
The environment is also relevant to the actual success of the meeting. We believe that Italy, hosting the oldest university in the world, could offer the unique opportunity to ISHR delegates and Italian cardiologists to enjoy the most advanced and modern scientific program in the same environment and the actual rooms where Copernicus, Paracelcius, Giotto, Michelangelo, Harvey, Galileus and Galvani studied and worked. We would like, for the first time ever, to link the four oldest Italian universities as venues for the XIX ISHR World Congress and associated meetings in 2007.
In addition, in 2007, the ISHR will undoubtedly be dealing with problems such as bio-ethics and globalisation of the research and of treatment for cardiovascular disease. What could be a better sight than the Vatican to discuss this? We are currently working on this prospect and hope to succeed.

The Idea
The idea is to offer the cardiological community and the ISHR delegates a four day meeting in Bologna, the oldest university in the world, preceded by one further day, focused on different subjects, in Padova, Ferrara or Pavia, the other three oldest universities in Italy. The major Sections of the ISHR have already decided to hold their annual meetings in 2007 in Italy, just before the main meeting in Bologna. The American Section will meet in Bologna, the European Section will meet in Padova, the Japanese Section will meet in Ferrara, and other Sections may meet in Pavia.
The scientific program for Bologna will deliberately be kept broad. Bologna will represent the “body” of Italy 2007, delegates who wish to do so will move to Bologna after attending a Section meeting or satellite. This is indeed possible, considering that Bologna is only 25 minutes by train from Ferrara, 45 minutes from Padova, and 90 minutes from Pavia. Rome – if we succeed with the Vatican - is 45 minutes from Bologna by plane and, in 2007, 120 minutes or even less by train!
In this way, the delegates will be able to enjoy the unique typical university atmosphere, to visit the enchanting old buildings hosting these universities and to explore the remarkable non-tourist sites of our country.

Monday, October 16, 2006

Infectious Diseases: Varicella-Zoster Infections

Varicella-Zoster Infections

Primary infection results in varicella (chickenpox), manifesting as a generalized, pruritic, vesicular rash typically consisting of 250 to 500 lesions in varying stages of development and resolution (crusting), mild fever, and other systemic symptoms. Complications include bacterial superinfection of skin lesions, pneumonia, central nervous system involvement (acute cerebellar ataxia, encephalitis), thrombocytopenia, and other rare complications such as glomerulonephritis, arthritis, and hepatitis. Varicella tends to be more severe in adolescents and adults than in young children. Reye syndrome can follow cases of chickenpox, although the incidence of Reye syndrome has decreased dramatically with decreased use of salicylates during varicella or influenza-like illnesses. In immunocompromised children, progressive severe varicella characterized by continuing eruption of lesions and high fever persisting into the second week of illness as well as encephalitis, hepatitis, and pneumonia can develop. Hemorrhagic varicella is more common among immunocompromised patients than immunocompetent hosts. Pneumonia is relatively less common among immunocompetent children but is the most common complication in adults. In children with human immunodeficiency virus (HIV) infection, recurrent varicella or disseminated herpes zoster can develop. Severe and even fatal varicella has been reported in otherwise healthy children receiving intermittent courses of high-dose corticosteroids (>2 mg/kg of prednisone or equivalent) for treatment of asthma and other illnesses. The risk especially is high when corticosteroids are given during the incubation period for chickenpox.
The virus establishes latency in the dorsal root ganglia during primary infection. Reactivation results in herpes zoster ("shingles"). Grouped vesicular lesions appear in the distribution of 1 to 3 sensory dermatomes, sometimes accompanied by pain localized to the area. Postherpetic neuralgia, which may last for weeks to months, is defined . . . [
Go to Full Text]

1. Centers for Disease Control and Prevention. Updated ACIP recommendations for varicella vaccine use. MMWR. 2006; in press (available at
Centers for Disease Control and Prevention. A new product (VariZIG) for postexposure prophylaxis of varicella available under an investigational new drug application expanded access protocol. MMWR Morb Mortal Wkly Rep. 2006;55:209–210[Medline]
3. Centers for Disease Control and Prevention. Prevention of varicella update: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 1999;48(RR-6):1–5[Medline]
4. Centers for Disease Control and Prevention. Prevention of varicella update: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Morb Mortal Wkly Rep. 1999;45(RR-6):1–5
5. American Academy of Pediatrics, Committee on Infectious Diseases. Recommendations for the use of live attenuated varicella vaccine. Pediatrics. 1995;95:791–796 (undergoing revision at the time of publication of Red Book) [Medline]

Visual Acuity in a Population

Changes in Visual Acuity in a Population Over a 15-year Period: The Beaver Dam Eye Study

Ronald Klein, MD, MPH, Barbara E.K. Klein et al.

American Journal of Ophthalmology
Volume 142, Issue 4, Pages 539.e1-539.e13 (October 2006) Full Text

Purpose.To describe the change in visual acuity in a 15-year period.
Design. Population-based study.
setting: Beaver Dam, Wisconsin. participants: 4068 persons 43 to 86 years of age at the time of a baseline examination in 1988 to 1990, and with follow-up examinations every five years thereafter. observation procedures: Best-corrected visual acuity after refraction, assessed by a modification of the ETDRS protocol. main outcome measure: Doubling of the visual angle; incidence of visual impairment.
Results. Eight percent of the population developed impaired vision (20/40 or worse), 0.8% developed severe visual impairment (20/200 or worse), 7% had doubling of the visual angle, and 2% had improved vision. People 75 years of age or older at baseline were more likely to develop impaired vision (odds ratio [OR] 12.8, 95% confidence interval [CI] 9.6 to 17.1, P < .001), doubling of the visual angle (OR 7.8, 95% CI 5.6 to 10.7, P < .001), and severe visual impairment (OR 20.6, 95% CI 9.5 to 44.8, P<0.001) compared with people younger than 75 years of age.
Conclusions. These data provide population-based estimates of the cumulative 15-year incidence of loss of vision over a wide spectrum of ages. In people 75 years of age or older the cumulative incidence of visual impairment accounting for the competing risk of death is 25%, of which 4% is severe, indicating a public health problem of considerable proportions as the US population in this age is expected to increase by 55% from 18 million in the year 2005 to 28 million by the year 2025.

Tuesday, October 10, 2006

Pre-natal origins of childhood leukemia

Pre-natal origins of childhood leukemia

Greaves M.

Leukaemia Research Fund Centre for Cell and Molecular Biology, Institute of Cancer Research, Chester Beatty Laboratories, 237 Fulham Road, London SW3 6JB, UK.

Chimeric fusion genes derived by chromosome translocation provide stable, sensitive and clone-specific markers for tracking the origins of leukemic cells and the natural history of disease and have been particularly informative in studies with twins concordant for leukemia and in retrospective scrutiny of archived neonatal blood spots. These data have indicated that in pediatric leukemia the majority, but not all, of the chromosome translocations arise, in utero, during fetal hemopoiesis, probably as initiating events. In most cases, functionally complementary and secondary genetic events are also required. These are acquired rapidly, and possibly in utero also, in infant acute lymphoblastic leukemia (ALL) but post-natally for most childhood ALL and acute myeloblastic leukemia (AML). An important consequence of the latter is a very variable and occasionally protracted post-natal latency (1-15 years). Another important corollary is that functional chromosomal translocations and pre-leukemic clones arise at a substantially higher frequency (approximately 100x) before birth than the cumulative incidence or risk of disease. These natural histories provide an important framework for consideration of key etiological events in pediatric leukemia.

Rev Clin Exp Hematol. 2003 Sep;7(3):233-45.

Transient leukemia

A prospective study of the natural history of transient leukemia (TL) in neonates with Down syndrome (DS): Children's Oncology Group (COG) study POG-9481.

Massey GV, Zipursky A
Virginia Commonwealth University, Medical College of Virginia, PO Box 980121, Richmond, VA 23298, USA.

A unique transient leukemia (TL) has been described in newborns with Down syndrome (DS; or trisomy 21 mosaics). This leukemia has a high incidence of spontaneous remission; however, early death and subsequent development of acute megakaryoblastic leukemia (AMKL) have been reported. We prospectively evaluated 48 infants with DS and TL to determine the natural history and biologic characteristics of this disease, identify the clinical characteristics associated with early death or subsequent leukemia, and assess the incidence of subsequent leukemia. Blast cells associated with TL in DS infants exhibited FAB M(7) morphology and phenotype. Most infants (74%) had trisomy 21 (or mosaicism) as the only cytogenetic abnormality in the blast cells. Most children were able to spontaneously clear peripheral blasts (89%), normalize blood counts (74%), and maintain a complete remission (64%). Early death occurred in 17% of infants and was significantly correlated with higher white blood cell count at diagnosis (P < .001), increased bilirubin and liver enzymes (P < .005), and a failure to normalize the blood count (P = .001). Recurrence of leukemia occurred in 19% of infants at a mean of 20 months. Development of leukemia was significantly correlated with karyotypic abnormalities in addition to trisomy 21 (P = .037). Ongoing collaborative clinical studies are needed to determine the optimal role of chemotherapy for infants at risk for increased mortality or disease recurrence and to further the knowledge of the unique biologic features of this TL.

Blood. 2006 Jun 15;107(12):4606-13. Epub 2006 Feb 9.

Monday, October 09, 2006

Neonatal Septicemia

Blood Cell Deformation in Neonates Who Have Sepsis

Otwin Linderkamp, Johannes Pöschl, Peter Ruef
Division of Neonatology, Department of Pediatrics, University of Heidelberg, Heidelberg, Germany

Objectives. After completing this article, readers should be able to:
1- Describe alterations of red blood cells due to bacterial toxins.
2- Describe physical alterations of neutrophils during activation.
3- Delineate the role of red and white blood cells in the impairment of microcirculation and organ damage in sepsis.
4- List drugs that may inhibit neutrophil activation and improve their deformability and their actions.

Introduction. Sepsis remains a major cause of morbidity and mortality in neonates, particularly among preterm infants. (1) Impaired microcirculatory blood flow plays a pivotal role in the development of clinical manifestations and organ dysfunctions in severe sepsis and septic shock. (2)(3)(4) If not corrected, microcirculatory dysfunction can progress to organ dysfunction and subsequently to organ failure and death. Restoration of microcirculatory dysfunction is, therefore, an important step in preventing long-term sequelae (including brain damage) and death of the patient.
Both red and white blood cells must deform to pass through narrow channels whose diameters are less than those of the cells. (5) Impaired deformability of red and white blood cells may contribute to impaired microcirculatory blood flow in septicemia.

Impaired Deformability of Red Blood Cells in Neonatal Septicemia.
The membranes of neonatal red blood cells (RBCs) deform more in response to a given force than adult cells and are, therefore, more flexible. (6)(7) On the other hand, neonatal RBCs are larger and require higher pressures to enter filter pores and micropipettes that have diameters below the resting cellular diameters. (8)(9) The larger volume and increased deformability of neonatal RBCs are responsible for another favorable property, the increased Fahraeus and Fahraeus-Lindqvist effect (ie, hematocrit and viscosity reduction when going from 500- to 50-mcm tubes). (10) These favorable flow properties of neonatal RBCs suggest that their increased cellular deformability is a prerequisite for . . . [Full Text of this Article]

NeoReviews Vol.7 No.10 2006 e517
© 2006 American Academy of Pediatrics

Electronic Fetal Monitoring

Electronic Fetal Monitoring Case Review Series

Maurice L. Druzin, MDJulie M.R. Arafeh, RN, MSN

Electronic fetal monitoring (EFM) is a popular technology used to establish fetal well-being. Despite its widespread use, terminology used to describe patterns seen on the monitor has not been consistent until recently. In 1997, the National Institute of Child Health and Human Development (NICHD) Research Planning Workshop published guidelines for interpretation of fetal tracings. This publication was the culmination of 2 years of work by a panel of experts in the field of fetal monitoring and has been endorsed by both the American College of Obstetricians and Gynecologists (ACOG) and the Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN). The terminology definitions and assumptions found in the NICHD publication form the basis for interpretation of the fetal tracings in this series and are summarized here.
Assumptions from the NICHD Workshop:
- Definitions are developed for visual interpretation
- Definitions apply to tracings generated by internal or external monitoring devices
- Periodic patterns are differentiated based on waveform, abrupt or gradual (eg, late decelerations have a gradual onset and variable decelerations have an abrupt onset)
- Long- and short-term variability are evaluated visually as a unit
- Gestational age of the fetus is considered when evaluating patterns
- Components of fetal heart rate (FHR) do not occur alone and generally evolve over time
Definitions/ Baseline Fetal Heart Rate
- Approximate mean FHR rounded to increments of 5 beats/min in a 10-minute segment of tracing, excluding periodic or episodic changes, periods of marked variability, and segments of baseline that differ by >25 beats/min
- In the 10-minute segment, the minimum baseline duration must be at least 2 minutes or the baseline for that segment is indeterminate
- Bradycardia is a baseline of <110>Full Text of this Article]

NeoReviews Vol.7 No.7 2006 e374
© 2006 American Academy of Pediatrics

Sunday, October 08, 2006



S. Philip Morgan(1) and ­ Miles G. Taylor(2)­

1) Department of Sociology, Duke University, Durham, North Carolina 27708;
2) Carolina Population Center, University of North Carolina, Chapel Hill, North Carolina;

In the past few decades, demographic concerns have shifted from rapid population growth fueled by high fertility to concerns of population decline produced by very low, sub-replacement fertility levels. Once considered a problem unique to Europe or developed nations, concerns now center on the global spread of low fertility. Nearly half of the world's population now lives in countries with fertility at or below replacement levels. Further, by the mid-twenty-first century three of four countries now described as developing are projected to reach or slip below replacement fertility. We review the research on low fertility through the predominant frameworks and theories used to explain it. These explanations range from decomposition and proximate determinant frameworks to grand theories on the fundamental causes underlying the pervasiveness and spread of low fertility. We focus on the ability of theory to situate previous and future findings and conclude with directions for furthur research.

Annual Review of SociologyVol. 32: 375-399 Full Text

First published online as a Review in Advance on April 21, 2006

Anorexia nervosa

Ana and the Internet: A review of pro-anorexia websites

Mark L. Norris, MD(1), Katherine M. Boydell, PhD(2, 3), Leora Pinhas, MD (3,4), Debra K. Katzman, MD (3,5)

1) Paediatric Medicine and Adolescent Health, The Department of Paediatrics, University of Ottawa, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada;
2) Department of Public Health Sciences, Community Health Systems Resource Group, University of Toronto, Toronto, Canada
3) The Hospital for Sick Children, 555 University Ave., Toronto, Ontario, Canada 4) Department of Child and Adolescent Psychiatry, University of Toronto, Toronto, Canada 5) Department of Paediatrics, Division of Adolescent Medicine, University of Toronto, Toronto, Canada

Inc. Int J Eat Disord Volume 39, Issue 6 , Pages 443 - 447

Objective: The purpose of this article is to describe the content of pro-anorexia websites, both qualitatively and quantitatively.

Method: An Internet search protocol was developed to identify pro-anorexia websites. A grounded theory approach was used to generate themes from Internet-based information. Basic descriptive analysis was employed to report on key website characteristics.

Results: Twenty pro-anorexia websites met inclusion criteria. Saturation of themes was achieved after review of 12 websites. Key website characteristics included purpose of website (75%), information about webmaster (67%), website disclaimers (58%), and information on tips and tricks (67%). Religious metaphors, lifestyle descriptions, and thinspiration (inspirational photo galleries and quotes that aim to serve as motivators for weight loss) were frequently present. A total of 10 themes were generated. The most prevalent themes included control, success, and perfection.

Conclusion: Health-care providers and caregivers should be aware of pro-anorexia websites and their content, as these websites contain information that promote and support anorexia nervosa.

© 2006 by Wiley Periodicals, Inc. Int J Eat Disord 2006

Saturday, October 07, 2006

Coronary artery disease

Short- and Long-Term Prognosis After Acute Myocardial Infarction in Men Versus Women

Huiberdina L. Koek MD, PhD(a), Agnes de Bruin MSc(c), Fred Gast MSc(c), Evelien Gevers MSc(b), Jan W.P.F. Kardaun MD, PhD(c), Johannes B. Reitsma MD, PhD (d) Diederick E. Grobbee MD, PhD(a) and Michiel L. Bots MD, PhD(a).

a) Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands; b) Prismant, Utrecht, The Netherlands; c) Statistics Netherlands, Voorburg, The Netherlands; d) Department of Clinical Epidemiology and Biostatistics, Academic Medical Center, Amsterdam, The Netherlands.

The American Journal of Cardiology Volume 98, Issue 8 , 15 October 2006, Pages 993-999

The prevailing view is that women have a higher early mortality after acute myocardial infarction (AMI) than men, but several studies have shown no differences. Further, long-term differences have not been addressed widely. The present study examined gender differences in short- and long-term prognoses after AMI in The Netherlands. A nationwide cohort of 21,565 patients with a first hospitalized AMI in 1995 was identified through linkage of the National Hospital Discharge Register and the population register. Crude short- and long-term mortalities were significantly higher in women than in men (28-day hazard ratio [HR] 1.70, 95% confidence interval [CI] 1.58 to 1.82; 5-year HR 1.52, 95% CI 1.46 to 1.59). After adjustment for age, the risk difference was attenuated at 28 days and even reversed at 5 years in favor of women (28-day HR 1.11, 95% CI 1.03 to 1.20; 5-year HR 0.94, 95% CI 0.90 to 0.99). When differences in other covariates were also taken into account, the risk differences remained virtually the same. To account for differences in reperfusion procedures, we repeated the analyses in 1,176 patients who underwent acute reperfusion therapy (angioplasty/thrombolysis). Comparable, but not statistically significant, gender differences were observed (28-day HR 1.06, 95% CI 0.65 to 1.74; 5-year HR 0.82, 95% CI 0.62 to 1.08).
In conclusion, our findings in an unselected cohort covering a complete nation indicate that the worse short- and long-term prognoses after an AMI in women compared with men may largely be explained by differences in age, whereas differences in co-morbidity, origin, infarct location, and reperfusion therapy seem to contribute little.

Improved Preventive Care for Asthma

Improved Preventive Care for Asthma:
A Randomized Trial of Clinician Prompting in Pediatric Offices

Jill S. Halterman, MD, MPH; Susan Fisher, PhD; Kelly M. Conn, MPH; Maria Fagnano, BA; Kathleen Lynch, BA; Andrew Marky, BA; Peter G. Szilagyi, MD, MPH

Arch Pediatr Adolesc Med. 2006;160:1018-1025.

Objective To determine whether clinician prompting regarding a child's symptom severity and guideline recommendations at the time of an office visit improves the delivery of preventive asthma care.

Design Randomized controlled trial.

Setting Two inner-city pediatric practices in Rochester, NY.

Participants Two hundred twenty-six children with persistent asthma (aged 2-12 years) presenting to the clinics for well-child care, asthma care, or non–asthma-related illness care.

Intervention We assigned children randomly to a clinician-prompting group (single-page prompt including the child's symptoms and guideline recommendations given to the clinician at the time of the visit) or a standard-care group (no prompt given). Interviewers called parents after the visit to inquire about preventive measures taken, and medical charts were reviewed.

Main Outcome Measures Any preventive action related to asthma taken at the visit.

Results Children in the clinician-prompting group were more likely to have had any preventive measures taken at the visit compared with children in the standard-care group (87% vs 69%). Specifically, visits for children in the clinician-prompting group were more likely to include delivery of an action plan (50% vs 24%), discussions regarding asthma (87% vs 76%), and recommendations for an asthma follow-up visit (54% vs 37%). In a regression model, children in the clinician-prompting group had 3-fold greater odds of receiving any preventive action compared with the standard-care group.

Conclusion Clinician prompting regarding asthma severity and care guidelines at the time of an office visit significantly improved the delivery of preventive asthma care.

Author Affiliations: Departments of Pediatrics (Drs Halterman and Szilagyi; Mss Conn, Fagnano, and Lynch; and Mr Marky) and Community and Preventive Medicine (Dr Fisher), University of Rochester School of Medicine and Dentistry, and the Strong Children's Research Center (Drs Halterman and Szilagyi; Mss Conn, Fagnano, and Lynch; and Mr Marky), Rochester, NY.

Friday, October 06, 2006

Hepatitis B, immunization

Academy endorses CDC's hepatitis B recommendation

The Academy has endorsed the Centers for Disease Control and Prevention (CDC) recommendation for hepatitis B vaccine, A Comprehensive Immunization Strategy to Eliminate Transmission of Hepatitis B Virus Infection in the United States. The CDC recommends that all newborns receive a birth dose of hepatitis B vaccine before leaving the hospital unless a physician provides a written order to defer the birth dose. CDC also recommends that all children age 19 and younger receive the vaccine series.

Delay in 'rare circumstances'". 'On a case-by-case basis and only in rare circumstances," the birth dose may be delayed until after hospital discharge, according to the new recommendation. This exception applies only to infants who weigh at least 2,000 grams and whose mothers are known to be HBsAg negative during the current pregnancy. When a decision is made to delay the birth dose, a physician's order to withhold the birth dose and a copy of the original laboratory report indicating that the mother was HBsAg negative during this pregnancy must be placed in the infant's medical record.

In infants who do not receive a first dose before hospital discharge, the first dose should be administered no later than 2 months of age.

CDC recommendations also state that the birth dose should not be delayed if the infant's mother engaged in high-risk sexual or drug-using practices during pregnancy (e.g., having had more than one sex partner during the previous six months or an HBsAg-positive sex partner, evaluation or treatment for an STD, or recent or current injection-drug use) or in situations of expected poor compliance with follow-up to initiate the vaccine series.

Preterm infants weighing less than 2,000 grams and born to HBsAg-negative mothers should have their first vaccine dose delayed until one month after birth or hospital discharge, whichever comes first. For these infants, a copy of the original laboratory report indicating that the mother was HBsAg negative during this pregnancy should be placed in the infant's medical record.

The recommendations call for physician follow-up in infants whose birth dose is delayed.

Catch-up. Hepatitis B vaccination is recommended for all children and adolescents 19 years of age and under. Children and adolescents who have not previously received hepatitis B vaccine should be vaccinated routinely at any age with an appropriate dose and schedule, but all children aged 11-12 years should have a review of their immunization records and should complete the vaccine series if they were not previously vaccinated or were incompletely vaccinated.

© 2006 American Academy of Pediatrics



Theresa L. Charrois, BScPharm, MSc(a), Jessica Hrudey(a)
Sunita Vohra, MD, MSc(a,b)

a) On behalf of the American Academy of Pediatrics Provisional Section on Complementary, Holistic, and Integrative Medicine
b) Complementary and Alternative Research and Education (CARE) Program, Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada

Pediatrics in Review. 2006;27:385-387.

Introduction. Echinacea has been used for centuries in North American traditional medicine for a variety of conditions and currently is used primarily for the prevention and treatment of upper respiratory tract infections (URTIs). Research results on its efficacy for these indications have been mixed, but few adverse effects have been noted, with the exception of some allergies and rashes.
Definition and Description.
Echinacea, also known as purple coneflower, is native to North America. The three species used medicinally most often are E angustifolia, E pallida, and E purpurea. Most clinical studies have focused on E purpurea. (1) The properties of commercially available products differ regarding species used, plant part used, extraction method, and whether other plant extracts are included.
Evidence of Efficacy in Pediatrics. Few systematic reviews have summarized the efficacy of echinacea for the treatment and prevention of URTIs. Other reviews have concluded that there may be efficacy in the treatment but not necessarily in the prevention of URTIs in adults. (2)(3)(4) Because these reviews were not conducted systematically with explicit methods, the results and conclusions are subject to bias.
A recent updated Cochrane systematic review includes results from trials that involved both adults and children for the use of echinacea in the treatment or prevention of the common cold. (5)

The results can be summarized as follows:
Prevention trials with placebo comparison: no difference between groups
Treatment trials with no treatment comparison: one study had a trend in favor of echinacea; one study had no difference.

American Academy of Pediatrics.

Wednesday, October 04, 2006

The Leukemia & Lymphoma Society

Childhood Leukemia and Lymphoma: New Options for Treatment

Location: Free Teleconference
Date:October 17, 2006 - Tuesday

Beginning Time: 1:00 pm Eastern
End Time: 2:15 pm
Suggested Donation: N/A

Event Description:
Register online for this free telephone education program. This program will feature Sima Jeha, M.D., director, Leukemia/Lymphoma, Developmental Therapeutics Department of Oncology at St. Jude Children's Research Hospital. Participants will have the opportunity to ask questions during the program.
This program is sponsored by The Leukemia & Lymphoma Society and is supported by a grant from
The Jeff Gordon Foundation.

For more information contact: Information Resource Center 800-955-4572

Monday, October 02, 2006

Obesity in Early Childhood

Identifying Risk for Obesity in Early Childhood

Philip R. Nader, MD(a), Marion O'Brien, PhD(b), Renate Houts, PhD(c), Robert Bradley, PhD(d), Jay Belsky, PhD(e), Robert Crosnoe, PhD(f), Sarah Friedman, PhD(g), Zuguo Mei, MD(h), Elizabeth J. Susman, PhD(i) for the National Institute of Child Health and Human Development Early Child Care Research Network

a) Division of Community Pediatrics, University of California, San Diego, California;
b) Department of Human Development and Family Studies, University of North Carolina, Greensboro, North Carolina
c) Statistics and Epidemiology, Research Triangle Institute, Research Triangle Park, North Carolina
d) Center for Applied Studies in Education, University of Arkansas, Little Rock, Arkansas
e) Institute for Study of Children, Families and Social Issues, Birkbeck University of London, London, United Kingdom
f) Department of Sociology and Population Research Center, University of Texas, Austin, Texas
g) National Institute of Child Health and Human Development, Bethesda, Maryland
h) Division of Nutrition and Physical Activity, Centers for Disease Control and Prevention, Atlanta, Georgia
i) Department of Biobehavioral Health, Pennsylvania State University, University Park, Pennsylvania

OBJECTIVES. Our aim with this study was to assist clinicians by estimating the predictive value of earlier levels of BMI status on later risk of overweight and obesity during the middle childhood and early adolescent years.

METHODS. We present growth data from the National Institute of Child Health and Human Development Study of Early Child Care and Youth Development, a longitudinal sample of 1042 healthy US children in 10 locations. Born in 1991, their growth reflects the secular trend of increasing overweight/obesity in the population. Height and weight of participating children in the study were measured at 7 time points. We examined odds ratios for overweight and obesity at age 12 years comparing the frequency with which children did versus did not reach specific BMI percentiles in the preschool- and elementary-age periods. To explore the question of whether and when earlier BMI was predictive of weight status at age 12 years, we used logistic regression to obtain the predicted probabilities of being overweight or obese (BMI 85%) at 12 years old on the basis of earlier BMI.

RESULTS. Persistence of obesity is apparent for both the preschool and elementary school period. Children who were ever overweight (>85th percentile), that is, 1 time at ages 24, 36, or 54 months during the preschool period were >5 times as likely to be overweight at age 12 years than those who were below the 85th percentile for BMI at all 3 of the preschool ages. During the elementary school period, ages 7, 9, and 11 years, the more times a child was overweight, the greater the odds of being overweight at age 12 years relative to a child who was never overweight. Sixty percent of children who were overweight at any time during the preschool period and 80% of children who were overweight at any time during the elementary period were overweight at age 12 years. Follow-up calculations showed that 2 in 5 children whose BMIs were 50th percentile by age 3 years were overweight at age 12 years. No children who were <50th>6 times more likely to be overweight at age 12 years than those <50th>85th percentile, as well as with BMIs in the high reference range are more likely than children whose BMI is <50th percentile to continue to gain weight and reach overweight status by adolescence. Pediatricians can be confident in counseling parents to begin to address the at-risk child's eating and activity patterns rather than delaying in hopes that overweight and the patterns that support it will resolve themselves in due course. Identifying children at risk for adolescent obesity provides physicians with an opportunity for earlier intervention with the goal of limiting the progression of abnormal weight gain that results in the development of obesity-related morbidity.

Key Words: BMI • childhood obesity • longitudinal growth

Abbreviations: CDC—Centers for Disease Control and Prevention • NICHD—National Institute of Child Health and Human Development • OR—odds ratio • CI—confidence interval

PEDIATRICS Vol. 118 No. 3 September 2006, pp. e594-e601 (doi:10.1542/peds.2005-2801)

Effect of Maternal Smoking During Pregnancy

Effect of Maternal Smoking During Pregnancy on Offspring's Cognitive Ability: Empirical Evidence for Complete Confounding in the US National Longitudinal Survey of Youth

G. David Batty, PhD(a,b), Geoff Der, MSc (a) and Ian J. Deary, PhD (b)
a) Medical Research Council, Social and Public Health Sciences Unit, University of Glasgow, Glasgow, United Kingdom

b) Department of Psychology, University of Edinburgh, Edinburgh, United Kingdom

BACKGROUND. Numerous studies have reported that maternal cigarette smoking during pregnancy is related to lower IQ scores in the offspring. Confounding is a crucial issue in interpreting this association.

METHODS. In the US National Longitudinal Survey of Youth 1979, IQ was ascertained serially during childhood using the Peabody Individual Achievement Test, the total score for which comprises results on 3 subtests: mathematics, reading comprehension, and reading recognition. Maternal IQ was assessed by using the Armed Forces Qualification Test. There were 5578 offspring (born to 3145 mothers) with complete information for maternal smoking habits, total Peabody Individual Achievement Test score, and covariates.

RESULTS. The offspring of mothers who smoked 1 pack of cigarettes per day during pregnancy had an IQ score (Peabody Individual Achievement Test total) that was, on average, 2.87 points lower than children born to nonsmoking mothers. Separate control for maternal education (0.27-IQ-point decrement) and, to a lesser degree, maternal IQ (1.51-IQ-point decrement) led to marked attenuation of the maternal-smoking–offspring-IQ relation. A similar pattern of results was seen when Peabody Individual Achievement Test subtest results were the outcomes of interest. The only exception was the Peabody Individual Achievement Test mathematics score, in which adjusting for maternal IQ essentially led to complete attenuation of the maternal-smoking–offspring-IQ gradient (0.66-IQ-point decrement). The impact of controlling for physical, behavioral, and other social indices was much less pronounced than for maternal education or IQ.

CONCLUSIONS. These findings suggest that previous studies that did not adjust for maternal education and/or IQ may have overestimated the association of maternal smoking with offspring cognitive ability.
Key Words: smoking • pregnancy • IQ • cohort study

Abbreviations: NLSY79—US National Longitudinal Survey of Youth 1979 • PIAT—Peabody Individual Achievement Test

PEDIATRICS Vol. 118 No. 3 September 2006, pp. 943-950 (doi:10.1542/peds.2006-0168)