Charles W. Callahan

Internet-Based Home Monitoring and Education of Children With Asthma Is Comparable to Ideal Office-Based Care: Results of a 1-Year Asthma In-Home Monitoring Trial

OBJECTIVE. The goal was to determine whether home asthma telemonitoring with store-and-forward technology improved outcomes, compared with in-person, office-based visits. METHODS. A total of 120 patients, 6 to 17 years of age, with persistent asthma were assigned randomly to the office-based or virtual group. The 2 groups followed the same ambulatory clinical pathway for 12 months. Office-based group patients received traditional in-person education and case management. Virtual group patients received computers, Internet connections, and in-home, Internet-based case management and received education through the study Web site. Disease control outcome measures included quality of life, utilization of services, and symptom control. RESULTS. A total of 120 volunteers (45 female) were enrolled. The groups were clinically comparable (office-based: 22 female/38 male; mean age: 9.0 ± 3.0 years; virtual: 23 female/37 male; mean age: 10.2 ± 3.1 years). Virtual patients had higher metered-dose inhaler with valved holding chamber technique scores than did the office-based group at 52 weeks (94% vs 89%), had greater adherence to daily asthma symptom diary submission (35.4% vs 20.8%), had less participant time (636 vs 713 patient-months), and were older. Caregivers in both groups perceived an increase in quality of life and an increase in asthma knowledge scores from baseline. There were no other differences in therapeutic or disease control outcome measures. CONCLUSIONS. Virtual group patients achieved excellent asthma therapeutic and disease control outcomes. Compared with those who received standardized office-based care, they were more adherent to diary submission and had better inhaler scores at 52 weeks. Store-and-forward telemedicine technology and case management provide additional tools to assist in the management of children with persistent asthma.

Primary Tracheomalacia and Gastroesophageal Reflux in Infants with Cough

Cough is an uncommon sign in infants. Cough may result from the presence of abnormal secretions in the airway or abnormalities of the central airways that affect the infants ability to clear normal secretions. Tracheomalacia (TM) and gastroesophageal reflux (GER) can both cause cough in infants. Four infants whose cough began in the newborn period were diagnosed with TM and GER. Symptoms of central airway obstruction (homophonous wheeze or tracheal cough) suggested the diagnoses. In three patients, the diagnosis was made by barium esophagraphy and airway fluoroscopy. The infants responded to conservative and medical therapy for GER and to nebulized bronchodilators. Tracheomalacia and GER cause cough in infants that begins in the newborn period. The diagnosis can often be made with studies available to the primary care provider, and the conditions are often responsive to medical management.

Congestive Heart Failure in a Neonate Secondary to Bilateral Intralobar and Extralobar Pulmonary Sequestrations

Signs and symptoms of congestive heart failure (CHF) in a newborn include tachycardia, respiratory distress, feeding intolerance, irritability, and a weak cry. The neonate with CHF will usually have hepatosplenomegaly. Wheezing or crackles may be heard. Edema may be generalized, and a chest radiograph will usually reveal cardiomegaly. Differential diagnosis of CHF in a full-term newborn includes congenital heart disease, asphyxial cardiomyopathy, viral myocarditis, supraventricular tachycardia, diabetic cardiomyopathy, and arteriovenous malformations. In this report we describe the first documented newborn with CHF due to a coexisting bilateral intralobar sequestration (ILS) and extralobar sequestration (ELS), and summarize the cases of bilateral sequestrations previously reported in the English literature.

Bronchiectasis: abated or aborted?

could be argued that the remaining cases also resulted from chronic infectious or infl ammatory conditions, such as immunodefi ciency, ciliary dyskinesia, asthma or foreign body aspiration. In fact, where an etiology was determined in their series (62.2%), the causes refl ect what others have observed as the classic pathophysiology of this condition: the triad of chronic airway obstruction, infection and infl ammation [6] . It is not at all clear why some children develop bronchiectasis and others do not. One fascinating yet unexplained observation by Karadag’s group suggests a possible genetic predisposition in some populations. He reported a high rate of consanguinity among his patients, with 42.6% of children’s parents being fi rst or second degree relatives. The taboos against consanguinity are not as strong in many parts of the world where bronchiectasis is also more common. For example, the incidence of bronchiectasis among Alaska Native children in the Yukon-Kuskokwim delta region may be as high as 140/10,000 contrasted with 1/10,000 in another continental US series [5, 7] . Alaska is one of a handful of states in the US where marriage between fi rst cousins is legal. It is an area that requires additional research. For more than half a century, investigators have noticed the relationship between bronchiectasis and socioeconomic conditions, as ‘irreversible bronchiectasis is not commonly seen in the better social and economic classes’ [8] . In many parts of the world, indoor fi res for cooking, poor nutrition, low immunization rates, cultural impediments to medical adherence and inconsistent access to medical care may explain a higher prevalence In much of the world, the diagnosis of childhood bronchiectasis is uncommon. At our busy pediatric center serving the Pacifi c Rim, the diagnosis was made 14 times in 19 years [1] . It is either a rare condition or it is looked for infrequently. It can be argued simply from experience that the latter is true at times. In a survey of pediatricians at our medical center, 89% (32/36) had never diagnosed bronchiectasis. In fact, only physicians with more than 20 years in practice or those with pulmonary or infectious disease training had ever made the diagnosis. The apparent rarity of the condition leads to its inevitable description as an orphan disease, but may in fact refl ect what Dr. Merrill Sosman wrote nearly 50 years ago: ‘we see only what we look for, we recognize only what we know’ [2, 3] . Bronchiectasis is almost certainly not a rarity in many parts of the world, as Karadag et al. [4] argue in their pediatric survey in this issue of Respiration. They describe 111 children with noncystic fi brosis-associated bronchiectasis, examined over a 14-year period in their practice. The patients were school age children who usually experienced the onset of symptoms in early childhood. The association with a severe or with repeated infectious insults at an early age is consistent with the observations of other series [5] . For nearly one third of the children, Karadag determined the cause to be postinfectious. It

Increased diagnosis of asthma in hospitalized infants: the next target population for care management?

Hospitalization of children with asthma declined at our institution between 1996 and 2000, before stabilizing for the past 5 years. The ages of children hospitalized since 2000 were examined to see if the demographics of the hospitalized population have changed to better understand why the hospitalization rate has remained the same despite continued, aggressive screening and education efforts. Data were gathered for our hospital through the Department of Defense Medical Health System Management Analysis and Reporting System (M2). The mean age (± SD) of children hospitalized in 2003 (2.84 ± 2.53) was less than the mean age for 2000 and 2002 (4.85 ± 3.7 and 4.61 ± 4.45), respectively (p < 0.05), and more infants less than 2 years of age were hospitalized in 2003 (33/60, 55% p < 0.01) and 2004 (32/68, 47% p < 0.05) than in 2000 (19/70, 27%). The diagnosis of asthma in hospitalized infants and young children has increased over the past 5 years, suggesting better recognition and providing a new target population for intervention with early asthma controller therapy.

American pediatricians at war: a legacy of service.

* Abbreviations: AAP — : American Academy of Pediatrics MASH — : Mobile Army Surgical Hospital MEDCAP — : Medical Civic Action Program MILPHAP — : Military Provincial Hospital Assistance Program USARV — : US Army Vietnam USNR — : United States Naval Reserve American pediatricians have gone to war for almost as long as pediatrics has been a specialty. A decade after Jacobi, Osler, and Forchheimer founded the American Pediatric Society in 1888, pediatricians, or “pediatrists” as they were sometimes called, were serving with the American military on foreign soil. Across more than a century of service, the role of pediatricians in armed conflict has often been unclear to military and civilian leaders, fellow physicians, and at times even to members of their own specialty. In a 2003 site inspection of an overseas US military treatment facility, the assistant secretary of defense for health affairs was briefed about pediatricians. “Why would we need pediatricians here?” was his reply. Despite the confusion, every major conflict since the Spanish–American War has witnessed American military pediatricians serving in a variety of roles. From Cuba to Kandahar, the beaches of Normandy to Mosul, the century of service continues around the globe and forms the fabric of the story of America’s uniformed pediatricians today.1–3 At the close of the 19th century, pediatricians played a very different role than in today’s society. Pediatricians were considered specialists rather than primary care providers for children. There were very few pediatricians in America, and they mostly served in large academic centers or in urban hospitals. Because accurate records of medical specialists were not routinely kept at the time of the Spanish–American War, it is unclear how many pediatricians served in the US military during that conflict. Samuel Walter Kelley was one famous pediatrician whose record of service is known. Dr Kelley spent most of his adult life in Cleveland, where he was a professor of diseases of children in the Cleveland College of Physicians and Surgeons. He worked in Cleveland as both a pediatrist and a pediatric surgeon. He … Address correspondence to LTC Mark W. Burnett, Task Force Raider, 6th Squadron, 4th Cavalry Regiment, Combat Outpost Keating, Nuristan Province, Afghanistan. E-mail: mark.w.burnett{at}us.army.mil