Todd A. Florin

Beyond Cat Scratch Disease: Widening Spectrum of Bartonella henselae Infection

Bartonella henselae was discovered a quarter of a century ago as the causative agent of cat scratch disease, a clinical entity described in the literature for more than half a century. As diagnostic techniques improve, our knowledge of the spectrum of clinical disease resulting from infection with Bartonella is expanding. This review summarizes current knowledge regarding the microbiology, clinical manifestations, diagnostic techniques, and treatment of B henselae infection.

Physical Inactivity in Adult Survivors of Childhood Acute Lymphoblastic Leukemia: A Report from the Childhood Cancer Survivor Study

Purpose: To determine if adult survivors of childhood acute lymphoblastic leukemia (ALL) are less active (and more inactive) than the general population and to identify modifying factors. Patients and Methods: Physical activity was assessed by self-report in 2,648 adult survivors of the Childhood Cancer Survivor Study. Participants in the Behavioral Risk Factor Surveillance System (BRFSS) survey administered through the Centers for Disease Control and Prevention (CDC) were used as a comparison group. Results: Survivors had a mean age of 28.7 years (range, 18.0-44.0 years) and were a mean of 23.1 years from their cancer diagnosis (range, 16.0-33.8 years). In multivariate models, ALL survivors were more likely to not meet CDC recommendations for physical activity [odds ratio (OR), 1.44; 95% confidence interval (95% CI), 1.32-1.57] and more likely to be inactive (OR, 1.74; 95% CI, 1.56-1.94) in comparison with the BRFSS general population. Survivors treated with >20-Gy cranial radiotherapy were at particular risk. Compared with BRFSS participants and adjusted for age, race, and ethnicity, survivors were more likely to not meet CDC recommendations (females: OR, 2.07, 95% CI, 1.67-2.56; males: OR, 1.43, 95% CI, 1.16-1.76) and more likely to be inactive (females: OR, 1.86; 95% CI, 1.50-2.31; males: OR, 1.84; 95% CI, 1.45-2.32). Conclusions: Long-term survivors of childhood ALL are less likely to meet physical activity recommendations and more likely to report no leisure-time physical activity in the past month. This level of inactivity likely further increases their risk of cardiovascular disease, osteoporosis, and all-cause mortality. (Cancer Epidemiol Biomarkers Prev 2007;16(7):1356–63)

Variation in Emergency Department Diagnostic Testing and Disposition Outcomes in Pneumonia

OBJECTIVE: To describe the variability across hospitals in diagnostic test utilization for children diagnosed with community-acquired pneumonia (CAP) during emergency department (ED) evaluation and to determine if test utilization is associated with hospitalization and ED revisits. METHODS: We conducted a retrospective cohort study of children aged 2 months to 18 years with ED visits resulting in CAP diagnoses from 2007 to 2010 who were seen at 36 hospitals contributing data to the Pediatric Health Information System. Children with complex chronic conditions, recent hospitalization, trauma, aspiration, or perinatal infection were excluded. Primary outcomes included diagnostic testing, hospitalization, and 3-day ED revisit rates across hospitals. We examined variation in diagnostic testing among hospitals by using multivariable mixed-effects logistic regression. RESULTS: A total of 100 615 ED visits were analyzed. Complete blood count (median: 28.7%), blood culture (27.9%), and chest radiograph (75.7%) were the most commonly ordered ED diagnostic tests. After adjustment for patient characteristics, significant variation (P < .001) was found for each test examined across hospitals. High test-utilizing hospitals had increased odds of hospitalization compared with low-utilizing hospitals (odds ratio: 1.86 [95% confidence interval: 1.17–2.94]; P = .008). However, differences in the odds of ED revisit between the low- and high-utilizing hospitals were not significant (odds ratio: 1.21 [95% confidence interval: 0.97–1.51]; P = .09). CONCLUSIONS: Emergency departments that use more testing in diagnosing CAP have higher hospitalization rates than lower-utilizing EDs. However, ED revisit rates were not significantly different between high- and low-utilizing EDs. These results suggest an opportunity to reduce diagnostic testing for CAP without negatively affecting outcomes.

The Need for Vigilance: The Persistence of Lead Poisoning in Children

of postnatal system corticosteroids on mortality and cerebral palsy in preterm infants: effect modification by risk for chronic lung disease. Pediatrics. 2005;115:655–661 11. Lindner W, Vossbeck S, Hummler H, Pohlandt F. Delivery room management of extremely low birth weight infants: spontaneous breathing or intubation? Pediatrics. 1999;103:961–967 12. Aly H, Milner JD, Patel K, El-Mohandes AA. Does the experience with the use of nasal continuous positive airway pressure improve over time in extremely low birth weight infants? Pediatrics. 2004;114:697–702

Practice Variation in Acute Bronchiolitis: A Pediatric Emergency Research Networks Study

This global bronchiolitis study illustrates frequent lack of use and large variation in administration of EBSTs in infants hospitalized from EDs. BACKGROUND AND OBJECTIVES: Studies characterizing hospitalizations in bronchiolitis did not identify patients receiving evidence-based supportive therapies (EBSTs). We aimed to evaluate intersite and internetwork variation in receipt of ≥1 EBSTs during the hospital management of infants diagnosed with bronchiolitis in 38 emergency departments of pediatric emergency research networks in Canada, the United States, Australia, New Zealand, the United Kingdom, Ireland, Spain, and Portugal. We hypothesized that there would be significant variation, adjusted for patient characteristics. METHODS: Retrospective cohort study of previously healthy infants aged <12 months with bronchiolitis. Our primary outcome was that hospitalization occurred with EBST (ie, parenteral fluids, oxygen, or airway support). RESULTS: Out of 3725 participants, 1466 (39%) were hospitalized, and 1023 out of 1466 participants (69.8%) received EBST. The use of EBST varied by site (P < .001; range 6%–99%, median 23%), but not by network (P = .2). Significant multivariable predictors and their odds ratios (ORs) were as follows: age (0.9), oxygen saturation (1.3), apnea (3.4), dehydration (3.2), nasal flaring and/or grunting (2.4), poor feeding (2.1), chest retractions (1.9), and respiratory rate (1.2). The use of pharmacotherapy and radiography varied by network and site (P < .001), with respective intersite ranges 2% to 79% and 1.6% to 81%. Compared with Australia and New Zealand, the multivariable OR for the use of pharmacotherapy in Spain and Portugal was 22.7 (95% confidence interval [CI]: 4.5–111), use in Canada was 11.5 (95% CI: 3.7–36), use in the United States was 6.8 (95% CI: 2.3–19.8), and use in the United Kingdom was 1.4 (95% CI: 0.4–4.2). Compared with United Kingdom, OR for radiography use in the United States was 4.9 (95% CI 2.0–12.2), use in Canada was 4.9 (95% CI 1.9–12.6), use in Spain and Portugal was 2.4 (95% CI 0.6–9.8), and use in Australia and New Zealand was 1.8 (95% CI 0.7–4.7). CONCLUSIONS: More than 30% of infants hospitalized with bronchiolitis received no EBST. The hospital site was a source of variation in all study outcomes, and the network also predicted the use of pharmacotherapy and radiography.

Parental Smoking and Children's Behavioral and Cognitive Functioning

Publisher Summary This chapter reviews the effects of tobacco exposure, both prenatal and postnatal, on childrens behavior and cognition. Infants who are exposed to maternal smoking during pregnancy are at an increased risk for other toxic exposures. Mothers who smoke are more likely to drink and use illicit drugs. Women who smoke differ from women who do not in a number of psychosocial characteristics. Higher rates of unwanted pregnancies, difficulties in coping with stress, and lower self‐esteem are found more commonly among women who smoke compared to women who do not. Prenatal exposure to maternal smoking has been shown to adversely affect childrens performance on intelligence and achievement tests, as well as performance in school, although findings in this area are not as consistent as those for increased rates of behavior problems. Animal studies have confirmed that nicotine at doses not high enough to cause intrauterine growth retardation still acts as a neuroteratogen, thereby altering rodent brain development and behavior. Nicotine exposure to a prenatal brain may prematurely stimulate the shift from neuronal proliferation to differentiation, a shift normally occurring later in development.