Sanford N. Cohen

Dengue Hemorrhagic Fever at 60 Years: Early Evolution of Concepts of Causation and Treatment

SUMMARY During the decade of the 1960s, the epidemiology of a new dengue disease, dengue hemorrhagic fever and dengue shock syndrome (DHF/DSS), was described by collaborative research performed by Thai scientists from many institutions and by workers at the U.S. Armys SEATO Medical Research Laboratory in Bangkok, Thailand. Careful clinical and physiological studies provided the initial description of DSS. DSS cases were caused by each of the four dengue viruses (DENV) and not chikungunya (CHIK) virus or DENV 5 and 6, were associated with a secondary-type dengue antibody response in children over the age of 1 year, were associated with a primary antibody response in infants less than 1 year old whose mothers had neutralizing antibodies to all four DENV, were associated more frequently with secondary DENV 2 infections than those due to DENV 1 and 3, and were more common in females than males over the age of 3 years. Robust laboratory methods for growth and recovery of DENV in tissue cultures were introduced. In addition, life-saving principles of fluid and plasma protein resuscitation of hypovolemia were described. Most epidemiological observations made during the decade of the 1960s have been confirmed in the succeeding 45 years. Much contemporary research on pathogenesis fails to address the two distinct immunological antecedents of DHF/DSS.

Use of Emergency Medical Service transport system in medical patients up to 36 months of age.

Objectives To determine the frequency of inappropriate transport by Emergency Medical Service (EMS). Design A retrospective study. Subjects Patients up to 36 months of age with medical complaints transported by EMS to an urban pediatric emergency department (ED). Interventions None. Measurements Arbitrary criteria for appropriate use of EMS transport system were developed. The age, triage status, number of previous uses of EMS, health insurance status, time of calls, chief complaint, and clinical management of patients in the ED were determined. The frequency of inappropriate use of EMS was determined and also the percentage of patients up to 36 months of age who used EMS transport system on more than one occasion. Results Charts of 341 patients were reviewed of which 126 patients (37%) could have been transported by nonemergent vehicles according to our arbitrary criteria. In addition 97 (28%) of these patients had used the EMS transport system on at least one other occasion. Conclusions EMS is utilized for inappropriate transportation in approximately 37% of our pediatric patients less than 36 months of age with medical complaints. In addition, 28% of these same patients utilized the EMS system on more than one occasion. It would appear that education of care providers in the appropriate use of EMS and use of alternate means of transportation would make the system more efficient and productive.

Specifying and facilitating family involvement in services to persons with developmental disabilities

This paper recognizes the important role of family involvement in services to people with developmental disabilities. The paper presents a conceptualization of involvement that was an outcome of a qualitative study of involvement from the perspective of family members themselves. The authors identify a framework of family involvement the composition of which incorporates four system levels (i.e. the individual, program/agency, community, society) and the five role opportunities for family members (i.e. treatment agent, planner, advocate, evaluator, and consultant/educator). Barriers to involvement are then delineated and the authors autline a process for promoting family involvement: 1) contracting for involvement; 2) developing a support system for involvement; and 3) monitoring and evaluating involvement.

Pneumococcal bacteremia in pediatric patients.

Patients treated for pneumococcal bacteremia were prospectively evaluated over a 21-month period. Of 2,610 blood cultures obtained, 79 (3%) were positive for Streptococcus pneumoniae. Of these, 37 patients (47%) initially had a focus of infection, and 73 (92%) were reevaluated after the results of the blood culture were known. Two-thirds of these were evaluated within 24 hours of the blood culture being drawn; the remainder were seen between 24 and 72 hours after the initial visit. Twenty-three patients were febrile (greater than 37.4 C) on reevaluation. Six demonstrated persistence of the original disease, nine showed no focus of infection, seven developed a focus of infection, and one developed a second focus of infection. No patients with temperatures less than 37.4 C developed significant disease. A regimen for management of patients with pneumococcemia is given.

Incidence of serious infection in infants under age two months with fever.

&NA; Infants less than eight weeks of age in a busy urban emergency department were prospectively reviewed during a six‐month period, from October 1, 1981 to March 31, 1982. An axillary temperature of 37.8°C or higher was arbitrarily defined as significantly elevated. A total of 1,655 young infants were seen during this time period, with 122 having temperatures of 37.8°C or higher (7%). Four percent of the febrile patients were bacteremic. The degree of temperature elevation was not proportional to the severity of the illness. Total white blood cell count was less than 4,000/mm3 in two of the bacteremic patients. Cerebrospinal fluid pleocytosis was present in 13% of the patients undergoing lumbar puncture.

Therapeutics in the Pediatric Emergency Room

Specific therapeutic agents for treatment of acute asthma attacks, convulsions, cardiac arrhythmias, anaphylaxis, and poisoning are discussed. Emphasis is placed on care in avoiding overdosage or synergistic effects of drugs.

580 WHY NICU LENGTHS OF STAY DIFFER FROM FEDERAL GUIDE LINES

Length of stay data for 3124 high-risk newborns admitted to a Childrens Hospital NICU over 6 yrs were compared to Federal DRG-related mean and outlier lengths of stay. Federal figures markedly underestimated lengths of stay for these infants. The Federal mean (17.9 d) for infants <1000 g at birth (DRG-386) differs markedly from the 66.5 days we found. Almost 60% of our infants exceeded the federal outlier figure of 38 days. 90% of our infants >2500 g with major diagnoses (DRG-389) stay beyond the federal mean (4.7 d) and 27.5% beyond the Federal outlier. Major surgery added 4.5-28 days to the hospital stay of our infants. Bronchopulmonary dysplasia accounted for the longest stays.Most of the discrepancy is explained by the Federal use of the geometric mean which emphasizes low values in a distribution and minimizes high ones. When the distribution of length of stay is bimodal, as it is for the highest risk and smallest infants, then the geometric mean is a poor measure of central tendency. The population admitted to a tertiary care NICU differs from the general neonatal population in that it contains fewer early deaths and more infants with complicated, severe problems. The Federal guidelines divide infants into only three birthweight groups and fail to include important factors (e.g. major surgery, outborn status, or the need for ventilation) as criteria. These omissions and abbreviations led to a patient classification system for prospective payment of hospital costs that is bound to discourage hospitals from providing care for high-risk newborns.

A Psychiatric-Pediatric Liaison Program that Assesses Attitudes

Significant increases in the number of hours pediatricians devote to counseling families have been documented in the literature, However, approximately half of young pediatricians in practice believe their residency provided insufficient experience in managing psychosocial and developmental disorders. The Behavioral Pediatrics Program is offered in the first year of pediatric training. Based in the Neonatal Unit (inpatient) and the Continuity Care Clinic (outpatient), it emphasizes interviewing parents to help residents gain confidence in ambiguous situations. Data collected at the end of the WSU/CHM program’s first year indicated that residents’ actual experiences in the Neonatal and Continuity Care modules were strongly associated with their rating. The program had impact on resident views of the importance of interviewing and normal development, but resistance to learning psychosocial perspectives was also clear. A number of changes in the program were made after evaluation.

1051 LACK OF A ROLE FOR RENAL RENIN (RCRC) IN DETERMINING SUSCEPTIBILITY TO MYOGLOBINURIC RENAL FAILURE (ARF) IN THE ABSENCE OF CHANGES IN Na INTAKE

We have investigated the role of changes in RCRC (independent of Na intake) in determining susceptibility to ARF. RCRC was altered in either direction from control (Grp A - normal Na intake) in S.D. rats by 1% NaCl drinking + S.Q. DOCA for 4 wks (Grp B) or by a low Na diet for 6 wks (Grp C). For the next 5 days the animals were continued on the previous Na intake (Grp B1 & C1),normal Na intake (Grp B2 & C2), or 1% NaCl (Grp C3). On the 5th day the 24 hour urinary Na, C1 and Osm excretions were determined and random members from each group were sacrificed for RCRC determination. ARF was induced in the rest by injection of 10 mg/kg of 50% glycerol. Tail vein BUNs were done; results are shown (mean ± SEM). The number of animals in parenthesis.

SURVIVAL IN NECROTIZING ENTEROCOLITIS: A COOPERATIVE APPROACH

Prior reports of survival in neonates with NEC have contrasted results of operative versus nonoperative management. In the belief that a cooperative interdisciplinary approach would yield greater survival, we studied prospectively all neonates with NEC over a 24 month interval. All suspect neonates were evaluated by both neonatology and surgery. NEC was documented by ileus, bloody stools and pneumatosis and/or pathology in 73 cases. Twenty three additional survivors lacking pneumatosis were excluded. All were treated initially nonoperatively. Operation was performed only for complications of NEC using predetermined clinical criteria. The criteria differ somewhat from those previously reported. Of 41 treated nonoperatively, 30(73%) survived. In 8 of the 11 deaths, operation was refused because of irreverslble brain, cardiac or renal disease raising medical mortality inordinately. Of 32 operated cases, 26(81%) survived. In 2 of 6 deaths no attempt at salvage was made. Survival of all infants with NEC was 77%.The important measure of management protocols is survival of all infants with NEC rather than a comparison of medical and surgical results. This sizable series demonstrates that improved survival can result from use of predetermined protocols.