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Objective: To test whether a method of fingerstick blood sample collection onto filter paper could be used as an alternative screening method in the field in settings where environmental lead contamination is a high risk. Method: Members of the Pediatric Mobile Team of Children's Hospital of Michigan, Detroit, collected paired venous and capillary blood samples from 120 children, aged 6 months to 6 years, who presented for services at any of 7 sites located in decaying neighborhoods of older sections of Detroit. All samples were analyzed for lead content by graphite furnace atomic absorption spectrometry. Results: When filter paper samples with blood lead levels of 0.48 [micro]mol/L (10 [micro]/dL) or higher were compared with matched venous samples, the concordance coefficient was 0.96. The sensitivity and specificity of the filter paper samples relative to the venous samples for a cut-off of 0.48 [micro]mol/L (10 [micro]g/dL) or higher were 94% and 99%, respectively, with a positive predictive value of 97%. However, at a cutoff of 0.72 [micro]mol/L (15 [micro]g/dL, the sensitivity and specificity dropped to 75% and 98%, respectively, with filter paper samples underreporting blood lead values. At any cutoff point (0.48, 0.72, or 0.96 [micro]mol/L [ 10, 15, or 20 [micro]g/dL]), the filter paper method was highly specific for lead. Conclusions: Capillary filter paper sampling is an accurate and practical alternative to venous sampling for blood lead screening using 0.48 [micro]mol/L (10 [micro]g/dL) as the cutoff. The filter paper method predicts levels of 0.72 [micro]mol/L (15 [micro]g/dL) or higher less well. The cause of divergent values above 0. 72 [micro]mol/L (15 [micro]g/dL) is not clear. Environmental contamination of capillary filter paper, however, does not seem to be an explanation. Arch Pediatr Adolesc Med. 1998;152:455-458, The use of filter paper to collect fingerstick blood for a community program to screen for lead levels in the blood seems effective. The filter paper samples seem accurate and practical, giving highly accurate readings up to 15 micrograms/dL. At that point and higher, the accuracy is less than at levels below that, although there is no apparent reason why this should be. The samples were analyzed for lead content by graphite furnace atomic absorption spectrometry.

Objective: To develop and evaluate a new filter paper method to determine capillary blood lead levels accurately in children. Design: Paired comparison of lead levels determined in capillary whole blood dried on filter paper with lead levels in venous whole blood samples determined by a reference method. Setting: Children's Hospital of Michigan clinics, Detroit. Patients: One hundred children aged 9 months to 6 years. Interventions: Lead concentrations determined in capillary whole blood samples dried on filter paper were compared with concentrations measured in paired venous whole blood samples by a reference method. Main Outcome Measures: Comparability of the two lead assay methods was assessed with the concordance coefficient. The sensitivity, specificity, and positive predictivity of the capillary filter paper method relative to the reference method were determined at three intervention decision concentrations of blood lead defined by the Centers for Disease Control and Prevention. Results: There was high agreement between the two assay methods, with a concordance coefficient of 0.96. The capillary filter paper assay had a sensitivity of 90% and specificity of 90% for differentiating blood lead levels of 0.48 [mu]mol/L (10 [mu]g/dL or more. Blood lead levels of 0.72 [mu]mol/L (15 [mu]g/dL or more and 0.96 [mu]mol/L (20 [mu]g/dL or more were identified with 98% and 94% sensitivity and 98% and 99% specificity, respectively. Positive predictivity was 93%, 98%, and 97%, respectively, at the three blood lead concentration decision points. Conclusion: The capillary filter paper method for blood lead analysis described herein provides a convenient, sensitive, accurate, and inexpensive method to examine children for elevated blood levels., Blood lead tests for children that use a finger prick and filter paper method may be simpler, less costly, and more convenient than traditional tests that require drawing blood from the child's arm. The filter paper method requires pricking a finger and dripping blood onto 12 millimeter circles on a piece of filter paper and sending the paper for laboratory analysis. Researchers compared the accuracy of the filter paper method against blood drawn from arm veins in determining blood lead levels in 100 children aged 9 months to 6 years. They also compared these two methods on laboratory standard samples for accuracy and stability. The filter paper method gave true positive results in 90% of the samples with blood lead levels above 0.48 micromoles per liter (micromol/L), 98% of the samples above 0.72 umol/L, and 94% of the samples above 0.97 micromol/L. Filter paper samples remained stable up to five months when stored at room temperature.

This article reviews current and future problems in health care of the elderly, The elderly population in America currently comprises 28 million people, about 12 percent of the population, who consume about one third of all health care expenditures in the US. By 2020, the elderly population is expected to reach 64 million. The American Medical Association currently supports initiatives in elderly health care starting in medical school and continuing through geriatric emphasis in all specialties, encouragement of assessment of geriatric care during specialty certification procedures, and affiliations between nursing homes and resident training programs. The elderly face health problems such as higher disease prevalence, more frequent chronic illnesses, and more functional disability or activity limitation. It is sometimes forgotten that while some elderly become ill or impaired by the time they are 65, others remain vigorous through their 70s or later. In dealing with the elderly who do become ill, physicians frequent face complex geriatric medical problems, which are discussed. Medical care may be provided to the elderly in hospitals, nursing homes, or at home. Decreasing functional capacity may be as significant a problem as disease, and this includes visual and hearing impairment, falling, and incontinence. Issues in preventive gerontology are discussed. Mental health issues among the elderly include depression, related alcoholism, and suicide, as well as dementia. Substance abuse and elder abuse are two other issues with which physicians need to be familiar, and these are also discussed. Excessive medications and the potential for drug interactions are also a significant problem. Issues which should be addressed during the education of physicians about geriatrics are described, and the significance of ageism (stereotyping and discrimination against the aged) and ethical issues are discussed. There is much that physicians can do in meeting health needs of elderly America. (Consumer Summary produced by Reliance Medical Information, Inc.)

The Society of Surgical Oncology began 50 years ago as a group of surgeons who called it the James Ewing Society. In 1975, the name was changed to the Society of Surgical Oncology. This subspecialty attracts surgical residents who wish to work in the field of cancer surgery but still wish to maintain wide-ranging surgical experience. The Society is now working with other organizations such as the American Society of Clinical Oncology and the American Association for Cancer Research. Radiotherapeutic societies need to be added in order to have a multidisciplinary approach. Formal designation as a specialty from the American Board of Surgery has not occurred. There is a need to define the group broadly, and it should maintain a position of leadership by developing standards of performance in treating the common cancers. The Society should never compete with the general surgeon, but should provide support to the community surgeon, who is the first line of surgical defense. Support can take the form of education, training, setting standards with the general surgeon, and consulting on difficult cases. Surgical oncology programs have been established by the Society; about 30 surgeons graduate per year. Membership in the Society requires at least one year of surgical oncology training and evidence of productive inquiry, such as published papers and research. The Society should appoint a research committee, and should be prepared to issue 'white papers' on controversial and contemporary cancer issues from the surgical point of view. The impact on cancer care should be through the general surgical community, and the general surgeon should be supported. (Consumer Summary produced by Reliance Medical Information, Inc.)

Objectives: To determine the incidence of neonatal dehydration leading to rehospitalization, whether clinical and health services data could predict its occurrence, and the outcome of dehydrated infants. Methods: We employed a retrospective case-control design nested within a cohort of 51383 newborns weighing 2000 g or more, with a gestational age of 36 weeks or more born at 11 Kaiser Permanente hospitals during 1995 and 1996. Cases were 110 infants who were rehospitalized within 15 days of discharge with dehydration, and who either had 12% or greater weight loss or a serum sodium level of 150 mEq/L or greater. Controls were 402 randomly selected infants. We reviewed subjects' paper medical records and telephoned their families at 24 to 36 months of age to ascertain neurological outcomes. Results: Rehospitalization for dehydration occurred in 2.1 per 1000 live births (95% confidence interval [CI], 1.8-2.6). Among vaginal births, the most important risk factors were being born of a first-time mother (adjusted odds ratio [AOR], 5.5; 95% CI, 3.1-9.6); exclusive breastfeeding (AOR, 11.2; 95% CI, 3.9-32.6); maternal age equal to or older than 35 years (AOR, 3.0; 95% CI, 1.5-6.0); and gestational age younger than 39 weeks (AOR, 2.0, 95% CI, 1.2-3.5). Among cesarean births, having a birth hospitalization length of stay less than 48 hours was associated with dehydration (odds ratio [OR], 14.8; 95% CI, 1.4-154.1). Adherence to the American Academy of Pediatrics follow-up guideline did not decrease risk of readmission. Among surviving infants, 1 of 110 cases and 12 of 400 controls had evidence of possible neurological problems 24 to 36 months after discharge (P=.3). No cases of limb gangrene, amputation, or intracranial infarction occurred. Conclusions: In this population with good access to medical care, serious sequelae of neonatal dehydration are rare. Interventions to decrease the frequency of neonatal dehydration should focus on first-time mothers and those who breastfeed exclusively. Arch Pediatr Adolesc Med. 2002; 156:155-161

Objectives: To determine the prevalence of pica and its characteristics among children with sickle cell disease. Designs: Retrospective, observational study. Setting: An urban, ambulatory care, interdisciplinary center. Patients: The medical records of all 480 patients who visited the center from March 1, 1998, to June 30, 1999, were reviewed. Patients were excluded for history of stroke, long-term transfusions, pregnancy, acute illness, or age younger than 3 years. Main Outcome Measures: Sex, age, weight, height, Tanner stage, complete blood cell count, sickle cell genotype, pica history, and levels of iron, zinc, lead, and fetal hemoglobin (Hb). Results: Of 395 study patients, 134 (33.9%) reported pica. Ingested items included paper, foam, and powders. There was a significantly higher prevalence of pica among patients homozygous for Hb S (Hb SS, sickle cell anemia) compared with the combined group of double heterozygous patients with Hb SC, Hb SD, and Hb S[beta] thallasemia (S[[beta].sup.+] or S[[beta].sup.0]) (35.6% vs 25.5%; P = .03). Within genotype, mean Hb levels were significantly lower and reticulocyte counts were significantly higher in the patients with pica. Overall, the mean age of patients with pica was significantly lower; however, the prevalence was 23.3% (27/116) among those aged 10.0 to 14.9 years and 14.8% (8/54) among those aged 15.0 to 19.0 years. Within age groups, patients with pica weighed significantly less. Conclusions: Pica appeared to have an unusually high prevalence in patients with sickle cell disease and a correlation with lower Hb levels. It is unclear whether pica is a specific marker of disease severity, because our review did not show a relationship to increased number and duration of hospitalizations. The association between pica and low body weight suggests a nutritional effect on its prevalence. Arch Pediatr Adolesc Med. 2001;155:1243-1247

Objective: To evaluate the quality of documentation and user satisfaction with a structured documentation system for pediatric health maintenance encounters, using scanned paper-based forms to generate an electronic medical record. Design: (1) A retrospective medical record review comparing 16 structured (ST) records with 16 contemporanously created unstructured records, (2) a questionnaire evaluation of user satisfaction, and (3) an electronic records review of patients seen 1 year following the full implementation of the system to evaluate persistence of the effect. Setting: The Yale-New Haven Hospital Pediatric Primary Care Center, New Haven, Conn, an inner-city clinic in an academic center. Participants: (1) A random sample of 16 health maintenance records completed by first- and second-year residents in February 1996 matched for patients age and provider training level with 16 contemporaneously documented visits, (2) 16 of 18 pediatric level I residents and 14 of 16 pediatric level 2 residents who completed questionnaires, and (3) all electronic records of health maintenance visits during February 1997. Main Outcome Measures: The number of data elements documented and the percentage of records that record specific components of the health maintenance encounter. User satisfaction was specified on a Likert scale. Results: Overall, residents in the ST records group documented more data elements per visit than did those in the unstructured records group. The number of developmental items documented was 11.5 per visit in the ST records group and 4.8 per visit in the unstructured records group (P=.004). Likewise, anticipatory guidance was more thoroughly documented in the ST records group--8.3 items per visit vs 2.5 items per visit (P [is less than] .001). Ninety percent of the users preferred the ST records. One year after the adoption of the ST recording system, high levels of thoroughness persisted. Conclusions: Structured, scannable encounter forms can facilitate documentation of patient care and are well accepted by users. They can provide an effective mechanism to ease the transition to a computer-based patient record. Arch Pediatr Adolesc Med. 199 7; 151:124 7-1253, Structured, machine-readable medical record forms may facilitate thorough documentation of patient visits and the transition to computer-based medical records. Researchers at Yale-New Haven Hospital in Connecticut compared scannable patient encounter forms and traditional medical records used by pediatric residents. Those who used the structured forms documented more items, and preferred the forms to traditional records where details of the visit must be written-out. The scannable forms also provided prompts to remind the physician of important issues to discuss with the patient.

Objectives: To determine whether skin care practices with iodine-containing disinfectants are putting patients in the neonatal intensive care unit at risk for primary hypothyroidism. Cutaneous exposure to povidone-iodine antiseptic solutions may be a cause of primary hypothyroidism in neonates. Design: Prospective pilot study. Setting: Level Ill neonatal intensive care unit of a university-affiliated hospital. Participants: Sequential sample of 47 medical and surgical patients admitted to the neonatal intensive care unit who received cutaneous povidone-iodine applications in preparation for invasive or surgical procedures. Methods: Seven to 10 days after iodine exposure, capillary blood samples were obtained on filter paper blots for thyroid function testing and urine samples were collected to determine quantitative iodine concentrations. A plasma creatinine level was determined for each subject. Results: A total of47 patients were enrolled. The gestational ages of subjects ranged from 26 to 41 weeks (mean, 33.6 weeks); the male-to-female ratio was 28:19; and the birth weights ranged from 0.7 to 5.1 kg (mean, 2.42 kg). The thyroxine level ranged from 20 to 187 nmol/L (1.6 to 14.6 [mu]g/ dL) (mean, 102 nmol/L [7.9 [mu]g/dL]; reference, [is greater than or equal to] 90 nmol/L [is greater than or equal to] 7 [mu]g/dL]); and the thyrotropin level ranged from 0. 1 to 16.5 mU/L (mean, 6.4 mU/L; reference,, The use of iodine as an antiseptic during medical and surgical procedures on newborns may result in sufficient iodine entering the bloodstream to interfere with thyroid function. Researchers measured blood levels of thyroid hormones and urinary iodide levels in 47 neonatal intensive care unit patients between 7 and 14 days old. Urine iodide levels averaged 400 times greater than the normal range, although thyroid hormone levels were within normal range. However, other studies suggest there may be a lag time between high iodine levels and an adverse effect on thyroid function. Moreover, the fact that kidney function was mildly impaired in these newborns suggests that urinary iodide levels would have been higher with normal functioning. In addition, some infants had received drugs that suppress secretion of thyrotropin, which could cause a false positive result on tests for adequate thyroid functioning. Other antiseptics are available that work better and are not absorbed.

Objectives: To determine whether parents of student athletes plan to use the preparticipation physical examination (PPE) as their student athlete's only annual health evaluation, to identify factors associated with this decision, and to assess their knowledge about the objectives of PPEs and more comprehensive examinations. Design: Survey. Setting: General community, school-sponsored PPEs. Participants: A convenience sample of parents or guardians of high school student athletes who obtained a school-sponsored, multiple-station format PPE were surveyed by using an anonymous paper-and-pencil questionnaire. Questionnaires were completed by the parents of 381 of 763 student athletes who obtained PPEs (participation rate, 49.9%). Results: Thirty percent of the parents in this sample planned to use the PPE as their student athlete's only contact with a health care provider. Parents whose adolescent's health insurance provided for comprehensive health assessments were more likely than those without this benefit to plan a comprehensive care evaluation (75% vs 60%, respectively) (P = .01 by [[chi].sup.2] analysis). In addition to addressing problems that might affect sports participation, parents thought that the PPE visit should evaluate medical problems that are unrelated to athletics (34%), perform health screening procedures (22%), assess social or behavioral issues (16%), and provide immunizations (7%). Conclusions: Many parents plan to use the PPE as their student athlete's only scheduled contact with a health care provider; this decision may be influenced by factors that are related to access to health care and misperceptions with regard to the mission of these specialized examinations. For these adolescents, important medical, social, and behavioral needs may not be met. Consideration should be given to including elements of the PPE in health assessments that are performed by individual clinicians or expanding the scope of large-group, multiple-station format PPEs. (Arch Pediatr Adolesc Med. 1995;149:653-657), Parents may abandon regular comprehensive check-ups for their adolescent children when the children begin having preparticipation physical examinations (PPEs). PPEs are group exams intended only to ascertain the child's fitness for participation in school sports. A group of 381 parents of children having a PPE returned a questionnaire surveying how parental attitudes toward check-ups would be affected by their child having a PPE. Eighty-five percent had taken their child for a comprehensive check-up within the previous year and 96% within the prior two years. However, 33% indicated they would replace regular check-ups with the PPE. Seventy-five percent of parents whose insurance paid for check-ups planned to continue them compared with 60% of parents whose insurance did not. Relying on the PPE could prove problematic because it is not designed to address medical and social issues such as health screening, nutrition, substance abuse, sexuality, or immunization.

Personal and structural barriers that prevent the children of disadvantaged families from seeing a doctor must be eliminated. Low reimbursement rates and time-consuming paper work in billing Medicaid discourage doctors from accepting Medicaid patients. Sick-child, well-child, and preventative care are often not provided by the same person, which compromises continuity and coordination of care and therefore quality of care. Medicaid families often need more intensive services and a greater variety of services than is provided by health maintenance organization structures. Personal barriers include parental ignorance about the importance of preventative care, inconvenient office hours for working mothers, lack of child care for siblings, and language barriers. Integrated, community-based approaches, teamwork within the practice, and coordination between doctors and health departments would help to overcome personal and structural barriers to health care access.

Objective: To determine whether vaginal foreign bodies (VFBs) in prepubertal girls are associated with sexual abuse and whether evidence exists in earlier reports for such an association. Design: Retrospective case review. Setting: General pediatric clinic at Duke University Medical Center, Durham, NC. Participants: All 12 girls 10 years of age and under who, between 1985 and 1988, were seen in the general clinic and subsequently found to have VFBs. Interventions: None. Measurements and Results: Clinic protocol required referral of all children with vaginal bleeding, unusual discharge, or VFBs to the Child Protection Team at the medical center, which also served as a pediatric gynecology consultation service. Records for the 12 girls, whose mean age was 6.3 years, showed 19 visits for single, multiple, or recurrent VFBs. Two girls had concurrent sexually transmitted diseases. Eight met diagnostic criteria for confirmed sexual abuse; three, for suspected abuse, and in one, abuse status was unknown. Conclusions: Vaginal foreign bodies in young girls may be a previously unrecognized indicator of sexual abuse. Girls with VFBs should be evaluated for possible sexual abuse. Prospective studies on the suggested association between VFBs and sexual abuse need to be conducted. (Arch Pediatr Adolesc Med. 1994;148:195-200), Pre-teenage girls who are diagnosed with vaginal foreign bodies (VFB) may be victims of sexual abuse. Researchers reviewed medical records of 12 girls under age 11 who were diagnosed with a total of 28 VFBs. Most patients sought medical care for vaginal discharge, spotting or bleeding, or odor. Nearly half of the girls experienced more than one occurrence of VFBs. All patients had vaginal discharge and two girls were diagnosed with a sexually transmitted disease. Four girls had other vaginal infections. Genital abnormalities were observed in nine patients. Examination of the foreign bodies after removal revealed material including tissue paper, adult body hair, cotton balls, a plastic cap, and unidentifiable matter. Sexual abuse was confirmed in eight of eleven patients and suspected in two others. Eight victims identified their abuser, although no girl explained how the VFB was acquired.

Concern over the health of American soldiers who served in Vietnam led to a Congressional directive for health studies to be conducted among Vietnam veterans. Because the incidence of cancers of the greatest concern were found to be low in an initial study, a second study, the Selected Cancers Study, was initiated. This study used different techniques to determine whether the risk of selected rare cancers was increased in these veterans, particularly as a consequence of exposure to Agent Orange. Industrial and agricultural exposure to the herbicides and contaminants in Agent Orange are variably associated with an increased risk for some cancers. This article presents the findings regarding non-Hodgkin's lymphoma (NHL), and details on the research methods are described. Results of studies on other cancers are presented in two other papers in the December 1990 issue of Archives of Internal Medicine. The cancers selected for study were chosen because of an experimentally observed link with exposure to phenoxy-containing herbicides and chlorophenols. Agent Orange, used to deforest Vietnam, contained both types of agents. Past exposure to Agent Orange is difficult to measure, and such exposure could only be estimated by characterizing military service in terms of service branch, region in Vietnam served, years of service, and specific duties involving herbicide handling. Veterans who served in Vietnam, but not elsewhere, had an approximately 50 percent greater risk of developing NHL within about 15 to 25 years after military service, and this was statistically significant. In this study, which used cancer registries covering about 10 percent of the US population, this group comprised 99 people, a small number about whom it is difficult to draw conclusions. The results suggest that the risk of NHL does not correspond to known patterns of Agent Orange spraying, as sea-going Navy veterans, who had little opportunity for exposure, had the highest risk of NHL. Risk was not greater among those stationed in Vietnam during times of heaviest spraying. No other factor associated with risk for NHL could be identified, and antimalarial therapy and illicit drug use do not seem to explain the increased incidence. The study strongly suggests that the increased risk of Vietnam veterans to develop NHL is not related to Agent Orange exposure. (Consumer Summary produced by Reliance Medical Information, Inc.)

Peer review is a critical element in the editorial process at Archives of Pediatrics & Adolescent Medicine. The goals are to provide expert advice to the authors regarding their work, a check on the scientific validity of the data and methods, and information to the editors for use in their decision about the suitability of the paper for publication in the ARCHIVES.

In 1995, the Committee on Sports Medicine and Fitness of the American Academy of Pediatrics (AAP) published a position paper[1] on atlantoaxial instability in children with Down syndrome in which a previous statement on the same subject published in 1984[2] (Table) was retired. The 1995 statement includes several arguments that disfavor screening of children with Down syndrome for atlantoaxial instability.[1] Whereas some of these arguments are well founded, others lack substantive evidence that would support the statement. In the following discussion, I attempt to analyze some of these arguments made in the 1995 statement and provide a viewpoint that favors radiologic examinations of the cervical spine of children with Down syndrome., The 1995 American Academy of Pediatrics Statement on Atlantoaxial Instability in Persons with Down Syndrome may be too cautious in not supporting the screening of all children with the chromosomal defect. Atlantoaxial instability is excessive neck mobility, which may increase the risk of spinal cord compression. X-ray examination of the cervical spine can detect this complication of Down syndrome, and may protect active children from devastating spinal cord injury.

There is a 10 percent failure rate for first-time surgical repair of inguinal hernias (a loop of intestine that enters the inguinal canal, the passage through the lower abdominal wall that contains either spermatic cord in men or round ligament in women). The failure rate for repair of hernias that recur may be as high as 35 percent; this is because the already scarred and probably weakened tissue must be pulled together under tension to close the defect in the abdominal wall. The plug method corrects the defect without placing the tissues under tension. The author's 20-year experience with one method of repair for recurrent inguinal hernias is reported. This method is simpler to perform than conventional methods and may be performed under local anesthesia on an outpatient basis. This method uses a piece of polypropylene mesh which is rolled (like a piece of paper around a pencil) to form a plug. After the herniated loop of intestine is reduced back into the abdominal cavity, this plug is inserted into the defect in the abdominal wall, allowed to uncoil slightly and sutured in place. This method was used for 1402 patients over a 20 year period, with 1276 patients (91 percent) followed up for from 3 to 21 years. There were 21 failures (1.6 percent). It is concluded that the use of the 'plug' method significantly reduces the failure rate for repair of recurrent inguinal hernias and is recommended for these patients. (Consumer Summary produced by Reliance Medical Information, Inc.)