Robert D. Newman

Persistent Diarrhea Signals a Critical Period of Increased Diarrhea Burdens and Nutritional Shortfalls: A Prospective Cohort Study among Children in Northeastern Brazil

Persistent diarrhea (PD; duration >/=14 days) is a growing part of the global burden of diarrheal diseases. A 45-month prospective cohort study (with illness, nutritional, and microbiologic surveillance) was conducted in a shantytown in northeastern Brazil, to elucidate the epidemiology, nutritional impact, and causes of PD in early childhood (0-3 years of age). A nested case-control design was used to examine childrens diarrhea burden and nutritional status before and after a first PD illness. PD illnesses accounted for 8% of episodes and 34% of days of diarrhea. First PD illnesses were preceded by a doubling of acute diarrhea burdens, were followed by further 2.6-3.5-fold increased diarrhea burdens for 18 months, and were associated with acute weight shortfalls. Exclusively breast-fed children had 8-fold lower diarrhea rates than did weaned children. PD-associated etiologic agents included Cryptosporidium, Giardia, enteric adenoviruses, and enterotoxigenic Escherichia coli. PD signals growth shortfalls and increased diarrhea burdens; children with PD merit extended support, and the illness warrants further study to elucidate its prevention, treatment, and impact.

Longitudinal Study of Cryptosporidium Infection in Children in Northeastern Brazil

A prospective, 4-year cohort study of children born in an urban slum in northeastern Brazil was undertaken to elucidate the epidemiology of Cryptosporidium infection in an endemic setting, describe factors associated with Cryptosporidium-associated persistent diarrhea, and clarify the importance of copathogens in symptomatic cryptosporidiosis. A total of 1476 episodes of diarrhea, accounting for 7581 days of illness (5.25 episodes/child-year), were recorded: of these, 102 episodes (6.9%) were persistent. Cryptosporidium oocysts were identified in 7.4% of all stools, and they were found more frequently in children with persistent diarrhea (16.5%) than in those with acute (8.4%) or no (4.0%) diarrhea (P<.001). Low-birth-weight children and those living in densely crowded subdivisions were at greater risk for symptomatic infection. Disease course was highly variable and was not associated with the presence of copathogens. Recurrent Cryptosporidium infection and relapsing diarrhea associated with it were moderately common. In light of these data, the applicability of the current World Health Organization diarrheal definitions to Cryptosporidium-associated diarrheal episodes may need to be reconsidered.

Cryptosporidiosis in Northeastern Brazilian Children: Association with Increased Diarrhea Morbidity

To evaluate the impact of Cryptosporidium infection on diarrheal disease burden and nutrition status, a nested case-control study was done among children who were followed from birth in Fortaleza, Brazil. The diarrhea history and growth records of 43 children with a symptomatic diarrhea episode of cryptosporidiosis (case-children) were compared with those of 43 age-matched controls with no history of cryptosporidiosis. After Cryptosporidium infection, case-children < or = 1 year old experienced an excessive and protracted (nearly 2 years) diarrheal disease burden. Case-children < or = 1 year old with no history of diarrhea prior to their Cryptosporidium infection also experienced a subsequent increased diarrheal disease burden with an associated decline in growth. Control subjects experienced no change in their diarrhea burden over time. This study suggests that an episode of symptomatic Cryptosporidium infection in children < or = 1 year of age is a marker for increased diarrhea morbidity.

A longitudinal study of Giardia lamblia infection in north‐east Brazilian children

OBJECTIVEu2002To evaluate the epidemiology of Giardia lamblia infection, investigate factors which might be associated with clinical manifestations and recurrence, and examine the role of copathogens in disease course.

Perinatal Risk Factors for Infant Hospitalization With Viral Gastroenteritis

Context.u2003 A tetravalent vaccine against rotavirus, the most commonly identified etiologic agent of viral gastroenteritis (GE), has recently been licensed for use in the United States. Objective.u2003 To evaluate whether specific groups of infants might be at sufficiently high risk to warrant a focused rotavirus vaccine policy, we investigated perinatal risk factors for hospitalization with viral GE and rotavirus in the first year of life. Design.u2003 Population-based, case–control study. Setting.u2003 Washington State linked birth certificate and hospital discharge abstracts from 1987 through 1995. Patients.u2003 Infants, 1 through 11 months of age, hospitalized for viral GE (N = 1606) were patients in this study. Control subjects were 8084 nonhospitalized infants, frequency-matched to patients on year of birth. Primary Outcome Measure.u2003 Maternal and infant characteristics associated with infant hospitalization for viral GE. Results.u2003 We found a significant association between birth weight and the risk for hospitalization. Very low birth weight infants (<1500 g) were at the highest risk (odds ratio [OR] 2.6; 95% confidence interval [CI]: 1.6,4.1);, low birth weight infants (1500–2499 g), at intermediate risk (OR 1.6; 95% CI: 1.3,2.1); and large infants (>4000 g), at reduced risk (OR 0.8; 95% CI: 0.6,0.9). Other characteristics associated with GE hospitalization were male gender (OR 1.4; 95% CI: 1.3,1.6); maternal smoking (OR 1.2; 95% CI: 1.1,1.4); unmarried mother (OR 1.2; 95% CI: 1.1,1.4); Medicaid insurance (OR 1.4; 95% CI: 1.3,1.7); and maternal age <20 years (OR 1.2; 95% CI: 1.0,1.5). Infants born October through December were at decreased risk for hospitalization (OR 0.8; 95% CI: 0.7,0.9), as were infants born to Asian mothers (OR 0.5; 95% CI: 0.3,0.7), and infants born to mothers >34 years of age (OR 0.7; 95% CI: 0.6,0.9). Using these factors, the area under a receiver operating characteristic curve was 0.63. Therefore, to achieve a sensitivity of 90% in identifying high-risk infants, specificity would fall to 10%. Subanalyses of children admitted for viral GE during the peak of the Northwest rotavirus season (January to March) and children with confirmed rotavirus infection demonstrated similar risk factors and receiver operating characteristic curves. Conclusion.u2003 We conclude that a focused rotavirus vaccination policy using readily identifiable potential high-risk groups would be unlikely to prevent most infant hospitalizations associated with rotavirus infection. However, the safety of rotavirus vaccine in low birth weight and premature infants must be established, because these children appear to be at greater risk for hospitalization with viral GE and rotavirus.

Bupivacaine-induced seizures and ventricular fibrillation in a 13-year-old girl undergoing wound debridement

Bupivacaine is a commonly used local anesthetic in dental, ophthalmologic, and simple surgical procedures. Its current popularity derives from its potency and relatively long half-life. Widespread use of bupivacaine has resulted in sometimes severe adverse reactions when significant systemic absorption has occurred. This report documents a life-threatening event following use of bupivacaine, briefly reviews its neurotoxic and cardiotoxic effects, and raises questions about current management strategies when toxicity occurs.

Prescription opioids and overdose deaths.

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A wilderness medicine course for pediatric residents

Objective To design a structured curriculum to teach pediatric residents about wilderness medicine. Background An increasing number of children are involved in more rigorous and potentially risky outdoor activities. Despite the breadth of exposure characteristic of most pediatric residencies, we are aware of no formalized syllabus that prepares residents to both treat injuries sustained in outdoor pursuits, and help parents and children to prepare safely for such activities. Methods The first half of the course was designed to teach a broad range of topics in wilderness medicine through a series of readings, lectures, and field trips. The second half of the course involved a six-day course in wilderness skills. Results Over a three-week period, the major topics of wilderness medicine were thoroughly covered. The three residents involved in the planning and execution of the course felt that the course succeeded in tilling an important gap in their pediatric residency training. Conclusions The addition of a structured wilderness medicine elective to pediatric residencies, with or without a field component, may provide a valuable opportunity for pediatric residents to broaden their skills and knowledge base to include these increasingly important topics.

Notes from the Field: Public Health Response to a Human Immunodeficiency Virus Outbreak Associated with Unsafe Injection Practices — Roka Commune, Cambodia, 2016

Public Health Response to a Human Immunodeficiency Virus Outbreak Associated with Unsafe Injection Practices — Roka Commune, Cambodia, 2016 Ugonna C. Ijeoma, MD1,2; Sin Sansam, MD3; Sok Srun, MD3; Hoy Vannara, MD3; Sou Sanith, MD3; Tek Sopheap, MD3; Robert D. Newman, MD2; Renuka Gadde, MBA4; Selenic Dejana, MD2; Ahmed Saadani Hassani, MD2; Vanthy Ly, MD2; Bakary Drammeh, DrPH2; Anindya De, PhD2; Johnita Byrd, MS2; Naomi Bock, MD2

PLATINUM NEEDLES FOR ELECTROLYSIS.Read before the Section of Surgery and Anatomy, at the Forty-second Annual Meeting of the American Medical Association, held at Washington, D. C., May, 1891.

It is at present difficult to procure a small sized platinum needle, which is in every respect satisfactory to the operator. The needles on the market are deficient: for instance, the insulation is rough, uneven, and not smooth on an equal plane from the non-insulated point, to and over the beginning of the insulation, the point is too dull, and will not readily pass through cuticle and fascia; the non-insulated part is weak, and breaks off easily; the shaft, or the whole needle is not stiff enough to be easily pushed into the tissues, and on any attempt at use will bend. The shape of the point is also objectionable, and makes a hole at the point of entrance, instead of cutting evenly and pushing through the tissues more by dilatation, than in such a manner, so that on withdrawal of the needle the point of entrance contracts again, without