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COVID-19 has had a disproportionate impact on those of Black and Hispanic race/ethnicity, older adults, and those with chronic conditions such as diabetes and heart disease 3 Higher-risk patients and practices could be selected for public health interventions and educational campaigns to decrease transmission, reduce inequities, and encourage patientswith symptoms to seek care early Neighborhood-level information can provide a helpful context for health risk factors and outcomes 7,9 Furthermore, linking EHRs to neighborhood-level resources could help providers connect patients in need to nearby food pantries, community centers, and housing assistance Previous comparisons with Behavioral Risk Factor Surveillance System (BRFSS) data and the Centers for Disease Control and Prevention's 500 Cities estimates (based on BRFSS) showed similar prevalence estimates with EHR-based data 10 It is noteworthy that Massachusetts has unusually high insurance coverage, with only 2 9% uninsured in 2019,11 which increases the generalizability of the MDPHnet system to the population as a whole Clearly there are challenges in linking data from different sources, including how to link and match data, how to protect privacy, and obtaining institutional review board permission 14 Yet such linkages could lead to a greater understanding of risk factors for disease, hospitalization and death, and the development of interventions for and targeted outreach to special populations

New York City Health and Nutrition Examination Survey (NYC HANES) was a population-based cross-sectional survey of NYC adults conducted twice, in 2004 and again in 2013–2014, to monitor the health of NYC adults 20 years or older. While blood pressure was measured in both surveys, an auscultatory mercury sphygmomanometer was used to measure blood pressure in clinics in 2004, and an oscillometric LifeSource UA-789AC monitor was used in homes in 2013–2014. To assess comparability of blood pressure results across both surveys, we undertook a randomized study comparing blood pressure (BP) readings by the two devices. Blood pressure measuring protocols followed the 2013 Association for the Advancement in Medical instrumentation guidelines for non-invasive blood pressure device. Data from 167 volunteers were analyzed for this purpose. Paired t tests were used to test for significant difference in mean systolic and diastolic blood pressure between devices for overall and by mid-arm circumference categories. To test for systematic differences between the two devices, we generated Bland-Altman graphs. Sensitivity, specificity, and Kappa statistics were calculated to assess between-device agreement for high (≥ 130/80 mmHg) and not high (

Mercury is a toxic metal that can be measured in human blood and urine. Population-based biomonitoring from 2004 guided New York City (NYC) Department of Health and Mental Hygiene (DOHMH) efforts to reduce exposures by educating the public about risks and benefits of fish consumption—a predominant source of exposure in the general population—and removing mercury-containing skin-lightening creams and other consumer products from the marketplace. We describe changes in exposures over the past decade in relation to these local public health actions and in the context of national changes by comparing mercury concentrations measured in blood (1201 specimens) and urine (1408 specimens) from the NYC Health and Nutrition Examination Survey (NYC HANES) 2013–2014 with measurements from NYC HANES 2004 and National Health and Nutrition Examination Surveys (NHANES) 2003–2004 and 2013–2014. We found that NYC adult blood and urine geometric mean mercury concentrations decreased 46% and 45%, respectively. Adult New Yorkers with blood mercury concentration ≥ 5 μg/L (the New York State reportable level) declined from 24.8% (95% CL = 22.2%, 27.7%) to 12.0% (95% CL = 10.1%, 14.3%). The decline in blood mercury in NYC was greater than the national decline, while the decline in urine mercury was similar. As in 2004, Asian New Yorkers had higher blood mercury concentrations than other racial/ethnic groups. Foreign-born adults of East or Southeast Asian origin had the highest prevalence of reportable levels (29.7%; 95% CL = 21.0%, 40.1%) across sociodemographic groups, and Asians generally were the most frequent fish consumers, eating on average 11 fish meals in the past month compared with 7 among other groups (p

Depression is responsible for a large burden of disability in the USA. We estimated the prevalence of depression in the New York City (NYC) adult population in 2013–14 and examined associations with demographics, health behaviors, and employment status. Data from the 2013–14 New York City Health and Nutrition Examination Survey, a population-based examination study, were analyzed, and 1459 participants met the inclusion criteria for this analysis. We defined current symptomatic depression by a Patient Health Questionnaire (PHQ-9) score ≥ 10. Overall, 8.3% of NYC adults had current symptomatic depression. New Yorkers with current symptomatic depression were significantly more likely to be female, Latino, and unemployed yet not looking for work; they were also significantly more likely to have less than a high school education and to live in a high-poverty neighborhood. Socioeconomic inequalities in mental health persist in NYC and highlight the need for better diagnosis and treatment.

While gender and racial/ethnic disparities in cardiovascular disease (CVD) risk factors have each been well characterized, few studies have comprehensively examined how patterns of major CVD risk factors vary and intersect across gender and major racial/ethnic groups, considered together. Using data from New York City Health and Nutrition Examination Survey 2013–2014—a population-based, cross-sectional survey of NYC residents ages 20 years and older—we measured prevalence of obesity, hypertension, hypercholesterolemia, smoking, and diabetes across gender and race/ethnicity groups for 1527 individuals. We used logistic regression with predicted marginal to estimate age-adjusted prevalence ratio by gender and race/ethnicity groups and assess for potential additive and multiplicative interaction. Overall, women had lower prevalence of CVD risk factors than men, with less hypertension (p = 0.040), lower triglycerides (p

National examination surveys provide trend information on diabetes prevalence, diagnoses, and control. Few localities have access to such information. Using a similar design as the National Health and Nutrition Examination Survey (NHANES), two NYC Health and Nutrition Examination Surveys (NYC HANES) were conducted over a decade, recruiting adults ≥ 20 years using household probability samples (n = 1808 in 2004; n = 1246 in 2013–2014) and physical exam survey methods benchmarked against NHANES. Participants had diagnosed diabetes if told by a health provider they had diabetes, and undiagnosed diabetes if they had no diagnosis but a fasting plasma glucose ≥ 126 mg/dl or A1C ≥ 6.5%. We found that between 2004 and 2014, total diabetes prevalence (diagnosed and undiagnosed) in NYC increased from 13.4 to 16.0% (P = 0.089). In 2013–2014, racial/ethnic disparities in diabetes burden had widened; diabetes was highest among Asians (24.6%), and prevalence was significantly lower among non-Hispanic white adults (7.7%) compared to that among other racial/ethnic groups (P 9%), decreased from 26.9 to 18.0% (P = 0.269), though both were non-significant. While local racial/ethnic disparities in diabetes prevalence persist, findings suggest modest improvements in diabetes diagnosis and management.

The objective of this study was to measure change in obesity prevalence among New York City (NYC) adults from 2004 to 2013–2014 and assess variation across sociodemographic subgroups. We used objectively measured height and weight data from the NYC Health and Nutrition Examination Survey to calculate relative percent change in obesity (≥ 30 kg/m(2)) between 2004 (n = 1987) and 2013–2014 (n = 1489) among all NYC adults and sociodemographic subgroups. We also examined changes in self-reported proxies for energy imbalance. Estimates were age-standardized and statistical significance was evaluated using two-tailed T tests and multivariable regression (p

OBJECT There has been renewed interest in the application of concentrated antibiotic powder to surgical wounds as a method to decrease infection rates. While there is substantial medical literature describing the effectiveness and complications associated with vancomycin and gentamycin powders, very little has been reported regarding the safety and effectiveness of bacitracin powder in surgical wounds. In this paper the authors report their detailed analysis of potential bacitracin powder-related complications in a population of pediatric patients who underwent shunt surgery. METHODS A detailed retrospective analysis was completed of all CSF shunt surgeries performed by the corresponding author at a large children’s hospital between 2001 and 2013. This cohort consisted of many patients who were the subject of a previous report that showed the use of bacitracin powder in shunt wounds potentially decreased infection rates. Data were collected regarding the most common known complications of bacitracin, i.e., anaphylaxis, wound healing difficulties, and renal dysfunction. Data were stratified by typical demographic, medical, and surgical variables, including whether bacitracin powder was applied to wounds prior to closure. RESULTS A total of 597 patients were reviewed in the analysis: 389 underwent surgery without bacitracin powder and 208 had concentrated bacitracin powder applied to the wounds prior to closure. The application of bacitracin powder was not associated with anaphylaxis (n = 0 both groups) or with an increase in wound breakdown (n = 5 in the control group, n = 0 in the bacitracin powder group) or renal dysfunction (creatinine/estimated glomerular filtration rate) using both comparative and multivariate analyses between the 2 groups. The sample size evaluating renal function was significantly lower (range 6–320) than that of anaphylaxis and wound breakdown analysis because only clinical values acquired during the routine care of these patients were available for analysis. The only significant difference in demographics was the more frequent use of intrathecal vancomycin and gentamycin in patients who received bacitracin powder (n = 1 for controls, n = 21 for bacitracin powder). In the multivariate analysis, only 1 factor, surgery performed on a premature infant within the first 3 months of life, was independently associated with a change in creatinine at 3 months (creatinine decreased by 0.18) compared with the level before surgery (p < 0.0001). Bacitracin powder was not a significant factor. CONCLUSIONS To the authors’ knowledge, this is the first study to systematically analyze the potential complications of concentrated bacitracin powder applied to surgical wounds. The use of topical bacitracin powder in CSF shunt wounds was not associated with anaphylaxis, wound breakdown, or renal dysfunction. Further study using standardized protocols is necessary before widespread use can be recommended.

Electronic health records (EHRs) are transforming the practice of clinical medicine, but the extent to which they are being harnessed to advance public health goals remains uncertain. Data extracted from integrated EHR networks offer the potential for almost real-time determination of the health status of populations in care, for targeting interventions to vulnerable populations, and for monitoring the impact of such initiatives over time. This is especially true in ambulatory care settings, which are uniquely suited for monitoring population health indicators including risk factors and disease management indicators associated with chronic diseases. As efforts gather steam to integrate health data across delivery systems, large networks of electronic patient information are increasingly emerging. Few of the national population health surveillance systems that rely on EHR data have progressed beyond laying groundwork to launch and maintain EHR-based surveillance, but a limited number of more focused or local efforts have demonstrated innovation in population health surveillance. Common challenges include incompleteness of population coverage, lack of interoperability across data systems, and variable data quality. This review defines progress, opportunities, and challenges in using EHR data for population health surveillance.

An intradural somatic-to-autonomic anastomosis, or Xiao procedure, has been described to create a “skin-CNS-bladder” reflex that improves bladder and bowel function in patients with neurogenic bladder and bowel dysfunction. The authors present their experience with a 10-year-old boy with chronic neurogenic bladder and bowel dysfunction related to spinal cord injury who underwent the Xiao procedure. After undergoing a left L-5 ventral root to left S2–3 intradural anastomosis, the patient reported that his bladder and bowel dysfunction improved between 6 and 12 months. Two years after the procedure, however, he reported that there was no change in his bladder or bowel dysfunction as compared with his condition prior to the procedure. Frequent, systematic multidisciplinary evaluations produced conflicting data. Electrophysiological and histological evaluation of the previously performed anastomosis during surgical reexploration 3 years after the Xiao procedure revealed that the anastomosis was in anatomical continuity but neuroma formation had prevented reinnervation. Nerve action potentials were not demonstrable across the anastomosis, and stimulation of the nerve above and below the anastomosis created no bladder or perineal contractions. This is the first clinical report on the outcome of the Xiao procedure in a child with spinal cord injury outside of China. It is impossible to draw broad conclusions about the efficacy of the procedure based on a single patient with no demonstrable benefit. However, future studies should carefully interpret transient improvements in bladder function, urodynamic findings, and the patient's ability to void in response to scratching after the Xiao procedure. The authors' experience with the featured patient, in whom reinnervation could not be demonstrated, suggests that such changes could be related to factors other than the establishment of a skin-CNS-bladder reflex as a result of a somatic-to-autonomic anastomosis.

INTRODUCTION Electronic health records (EHRs) from primary care providers can be used for chronic disease surveillance; however, EHR-based prevalence estimates may be biased toward people who seek care. This study sought to describe the characteristics of an in-care population and compare them with those of a not-in-care population to inform interpretation of EHR data. METHODS We used data from the 2013-2014 New York City Health and Nutrition Examination Survey (NYC HANES), considered the gold standard for estimating disease prevalence, and the 2013 Community Health Survey, and classified participants as in care or not in care, on the basis of their report of seeing a health care provider in the previous year. We used χ(2) tests to compare the distribution of demographic characteristics, health care coverage and access, and chronic conditions between the 2 populations. RESULTS According to the Community Health Survey, approximately 4.1 million (71.7%) adults aged 20 or older had seen a health care provider in the previous year; according to NYC HANES, approximately 4.7 million (75.1%) had. In both surveys, the in-care population was more likely to be older, female, non-Hispanic, and insured compared with the not-in-care population. The in-care population from the NYC HANES also had a higher prevalence of diabetes (16.7% vs 6.9%; P < .001), hypercholesterolemia (35.7% vs 22.3%; P < .001), and hypertension (35.5% vs 26.4%; P < .001) than the not-in-care population. CONCLUSION Systematic differences between in-care and not-in-care populations warrant caution in using primary care data to generalize to the population at large. Future efforts to use primary care data for chronic disease surveillance need to consider the intended purpose of data collected in these systems as well as the characteristics of the population using primary care.

The New York City Department of Health has been developing two public health surveillance systems for chronic diseases. The first is the NYC Macroscope, which is built on a distributed query network of 740 New York City ambulatory practices all using proprietary software from one EHR vendor. The second model, Query Health, still in its initial phase, accesses data collected by a Health Information Exchange. This study compares these two models for potential disease surveillance and public health application.

The New York City (NYC) Department of Health and Mental Hygiene (Health Department) surveyed practicing NYC physicians to quantify Health Department resource use. Although the Health Department successfully reaches most physicians, and information is valued in practice, knowledge of several key resources was low. Findings suggested 3 recommendations for all local health departments seeking to enhance engagement with practicing physicians: (1) capitalize on physician interest, (2) engage physicians early and often, and (3) make interaction with the health department easy. Also, older physicians may require targeted outreach.

The objective of this study was to measure change in obesity prevalence among New York City (NYC) adults from 2004 to 2013-2014 and assess variation across sociodemographic subgroups. We used objectively measured height and weight data from the NYC Health and Nutrition Examination Survey to calculate relative percent change in obesity (≥ 30 kg/m

Health departments need the capacity to rapidly expand and modify surveillance during a changing outbreak., On April 23, 2009, the New York City Department of Health and Mental Hygiene (DOHMH) was notified of a school outbreak of respiratory illness; 2 days later the infection was identified as pandemic (H1N1) 2009. This was the first major outbreak of the illness in the United States. To guide decisions on the public health response, the DOHMH used active hospital-based surveillance and then enhanced passive reporting to collect data on demographics, risk conditions, and clinical severity. This surveillance identified 996 hospitalized patients with confirmed or probable pandemic (H1N1) 2009 virus infection from April 24 to July 7; fifty percent lived in high-poverty neighborhoods. Nearly half were

Hypophosphatasia (HPP) is a rare, heritable, metabolic bone disease due to deficient activity of the tissue-nonspecific isoenzyme of alkaline phosphatase. The infantile form features severe rickets often causing death in the first year of life from respiratory complications. There is no established medical treatment. In 1997, an 8-month-old girl with worsening and life-threatening infantile HPP improved considerably after marrow cell transplantation.Our aim was to better understand and to advance these encouraging transplantation results.In 1999, based on emerging mouse transplantation models involving implanted donor bone fragments as well as osteoblast-like cells cultured from bone, we treated a 9-month-old girl suffering a similar course of infantile HPP.Four months later, radiographs demonstrated improved skeletal mineralization. Twenty months later, PCR analysis of adherent cells cultured from recipient bone suggested the presence of small amounts of paternal (donor) DNA despite the absence of hematopoietic engraftment. This patient, now 8 yr old (7 yr after transplantation), is active and growing, and has the clinical phenotype of the more mild, childhood form of HPP.Cumulative experience suggests that, after immune tolerance, donor bone fragments and marrow may provide precursor cells for distribution and engraftment in the skeletal microenvironment in HPP patients to form tissue-nonspecific isoenzyme of alkaline phosphatase-replete osteoblasts that can improve mineralization.

There are few data comparing risk factors for catheter-related (CR) versus non-CR bloodstream infection (BSI) or for BSI caused by gram-positive versus gram-negative organisms. The aims of this study were to compare risk factors for CR versus non-CR BSI and to compare risk factors for BSI associated with gram-negative versus gram-positive organisms among infants hospitalized in two neonatal intensive care units (NICUs).Data were collected prospectively over a 2-year period to assess risk factors among 2,935 neonates from two NICUs.Among all neonates, in addition to low birth weight and presence of a central venous catheter, hospitalization in NICU 1 (relative risk [RR]: 1.60, 95% confidence intervals [CI]: 1.14, 2.24) was a significant predictor of BSI. In neonates with a central catheter total parenteral nutrition (TPN) was a significant risk factor for BSI (RR: 4.69, 95% CI: 2.22, 9.87). Ventilator use was a significant risk factor for CR versus non-CR BSI (RR: 3.74, 95% CI: 1.87, 7.48), and significantly more CR BSI were caused by gram-positive (77.1%) than by gram-negative organisms (61.4%), P = .03.This study confirmed that central venous catheters and low birth weight were risk factors for neonates with late-onset healthcare-associated BSI and further elucidated the potential risks associated with TPN and ventilator use in subgroups of neonates with BSI. Additional studies are needed to examine the incremental risk of TPN among infants with central venous catheters and to understand the link between CR BSI and ventilator use. Preventive strategies for BSI in neonates in NICUs should continue to focus on limiting the use of invasive devices.

The New York City (NYC) Department of Health and Mental Hygiene (Health Department) surveyed practicing NYC physicians to quantify Health Department resource use. Although the Health Department successfully reaches most physicians, and information is valued in practice, knowledge of several key resources was low. Findings suggested 3 recommendations for all local health departments seeking to enhance engagement with practicing physicians: (1) capitalize on physician interest, (2) engage physicians early and often, and (3) make interaction with the health department easy. Also, older physicians may require targeted outreach. [ABSTRACT FROM AUTHOR]

After the September 11, 2001 World Trade Center (WTC) disaster, recovery and clean-up efforts were concentrated at the WTC site and the Staten Island (SI) Fresh Kills landfill and barges. Research is limited regarding the long-term health effects of human remains exposure during clean-up and recovery work at the SI landfill and barges. We studied 1,592 WTC Health Registry enrollees who worked at the SI landfill, loading piers and barges after the 9/11/01 attacks to assess the relationship between remains exposure and persistent posttraumatic stress disorder (PTSD) 10-11 years later. A dose-response relationship was found between frequency of human remains exposure and persistent PTSD (adjusted odds ratio (AOR): every day (AOR) = 4.77; 95% confidence interval (CI): 2.00-11.52, almost every day (AOR) = 4.35; 95% CI: 1.75-10.80), and some days (AOR) = 2.98; 95% CI: 1.43-6.22). When exposed to human remains, sanitation workers had higher odds of persistent PTSD, compared to firefighters and police. In addition, respondents who scored lower on a social support scale had higher odds of persistent PTSD. The findings highlight the need for strategies to reduce the risk of PTSD associated with exposure to human remains in future disasters.

Electronic health records (EHRs) are increasingly being adopted to improve quality of care in health care systems, but they also have potential to monitor health at the population level. Enhancing existing surveillance methods with innovative EHR use allows for strategic targeting of health resources, and data to guide and evaluate public health initiatives and policies. New York City is currently developing the NYC Macroscope, aggregating EHR data into a surveillance tool to inform public health decisions. We have outlined key issues in developing an EHR-based surveillance system, and proposed indicators for the NYC Macroscope.

Purpose: Nephrolithiasis in preterm infants rarely requires surgical management. When it persists despite conservative therapy, treatment options are not clearly defined. We report a single institutional experience with extracorporeal shock wave lithotripsy (ESWL)* *Dornier Medical Systems, Inc., Marietta, Georgia. for the treatment of these small infants.Materials and Methods: We treated 8 infants (mean age 13 months) with a history of prematurity and 9 persistent stones with a Dornier HM3 lithotriptor between 1996 and 1999. Mean weight was 7,700 gm. Of the infants 7 had been treated with furosemide for bronchopulmonary dysplasia and 1 presented with multiple anatomical abnormalities. Gantry modification with a wooden platform and polystyrene foam positioning was used for lung and visceral protection. Ureteral stents were placed in 5 patients before ESWL. Renal ultrasonography was performed before, and 2 and a mean of 8 weeks after ESWL. Stone risk factors in our population were investigated through a mu...

An inverse relationship between mortality and center volume has been established for several surgical procedures. Given the distinctiveness of pediatric renal transplantation and the large variation in center volume, investigation for relationships between center volume and graft outcome was pursued using the North American Pediatric Transplant Cooperative Study database. Center volume groups were based on the total number of pediatric transplants reported from 1987 to 1995. Centers reporting >100, 51–100, or ≤50 transplants were grouped as high- (n=11), moderate- (n=28), or low-volume (n=65), respectively. Differences between groups included increasing rates of cadaver donor graft thrombosis (2.4%, 4.3%, and 5.7%, P

A 7-year-old boy with asthma was receiving the leukotriene receptor antagonist pranlukast (Ultair; SmithKline Beecham; Pittsburgh) as part of an open-label clinical trial. The patient's asthma improved, and he remained asymptomatic; but routine study evaluations 9 to 12 months into therapy showed microhematuria, proteinuria, glucosuria, anemia, and renal insufficiency. Renal biopsy demonstrated changes classic for acute allergic tubulointerstitial nephritis (ATIN), with mixed interstitial inflammatory infiltrate including eosinophils. Within 6 months of pranlukast withdrawal, anemia resolved and urinary sediment and renal function normalized. The case demonstrates that hypersensitivity reaction to pranlukast and resultant ATIN is possible, and that periodic urine testing in patients receiving pranlukast should be considered.

Mental health service utilization several years following a man-made or natural disaster can be lower than expected, despite a high prevalence of mental health disorders among those exposed. This study focused on factors associated with subjective unmet mental health care need (UMHCN) and its relationship to a combination of diagnostic history and current mental health symptoms, 5-6 years after the 9-11-01 World Trade Center (WTC) disaster in New York City, USA. Two survey waves of the WTC Health Registry, after exclusions, provided a sample of 36,625 enrollees for this analysis. Important differences were found among enrollees who were categorized according to the presence or absence of a self-reported mental health diagnosis and symptoms indicative of post-traumatic stress disorder or serious psychological distress. Persons with diagnoses and symptoms had the highest levels of UMHCN, poor mental health days, and mental health service use. Those with symptoms only were a vulnerable group much less likely to use mental health services yet reporting UMHCN and poor mental health days. Implications for delivering mental health services include recognizing that many persons with undiagnosed but symptomatic mental health symptoms are not using mental health services, despite having perceived need for mental health care.

Context The World Trade Center Health Registry provides a unique opportunity to examine long-term health effects of a large-scale disaster. Objective To examine risk factors for new asthma diagnoses and event-related posttraumatic stress (PTS) symptoms among exposed adults 5 to 6 years following exposure to the September 11, 2001, World Trade Center (WTC) terrorist attack. Design, Setting, and Participants Longitudinal cohort study with wave 1 (W1) enrollment of 71 437 adults in 2003-2004, including rescue/recovery worker, lower Manhattan resident, lower Manhattan office worker, and passersby eligibility groups; 46 322 adults (68%) completed the wave 2 (W2) survey in 2006-2007. Main Outcome Measures Self-reported diagnosed asthma following September 11; event-related current PTS symptoms indicative of probable posttraumatic stress disorder (PTSD), assessed using the PTSD Checklist (cutoff score ≥44). Results Of W2 participants with no stated asthma history, 10.2% (95% confidence interval [CI], 9.9%-10.5%) reported new asthma diagnoses postevent. Intense dust cloud exposure on September 11 was a major contributor to new asthma diagnoses for all eligibility groups: for example, 19.1% vs 9.6% in those without exposure among rescue/recovery workers (adjusted odds ratio, 1.5 [95% CI, 1.4-1.7]). Asthma risk was highest among rescue/recovery workers on the WTC pile on September 11 (20.5% [95% CI, 19.0%-22.0%]). Persistent risks included working longer at the WTC site, not evacuating homes, and experiencing a heavy layer of dust in home or office. Of participants with no PTSD history, 23.8% (95% CI, 23.4%-24.2%) reported PTS symptoms at either W1 (14.3%) or W2 (19.1%). Nearly 10% (9.6% [95% CI, 9.3%-9.8%]) had PTS symptoms at both surveys, 4.7% (95% CI, 4.5%-4.9%) had PTS symptoms at W1 only, and 9.5% (95% CI, 9.3%-9.8%) had PTS symptoms at W2 only. At W2, passersby had the highest rate of PTS symptoms (23.2% [95% CI, 21.4%-25.0%]). Event-related loss of spouse or job was associated with PTS symptoms at W2. Conclusion Acute and prolonged exposures were both associated with a large burden of asthma and PTS symptoms 5 to 6 years after the September 11 WTC attack.

Bartter syndrome, a group of disorders that encompasses multiple genetic defects with similar clinical presentation, has been divided into six different genotypes, according to different genetic defects, and into three main clinical variants (or phenotypes). Classic laboratory findings in all variants include hypochloremia, hypokalemia, and metabolic alkalosis with excessive excretion of chloride and potassium. Classic Bartter syndrome, neonatal Bartter syndrome, and Gitelman syndrome are the three main clinical variants. Classic Bartter syndrome and neonatal Bartter syndrome have defects in genes that affect transport channels in the ascending loop of Henle, where as in Gitleman syndrome the defect occurs in the transport channels of the distal convoluted tubule. Classic Bartter syndrome and neonatal Bartter syndrome have similar presenting symptoms, potential outcomes, and treatment, but different ages at presentation. Gitelman syndrome, a more benign condition than the other clinical variants, has the classic hallmark finding of hypomagnesemia and low to normal excretion of calcium. This differentiates it from the classic and neonatal variants of the disease. With early diagnosis and proper treatment, Bartter syndrome has a good prognosis. But failure to identify it can lead to tubulointerstitial nephritis and renal failure. We present a case of a 6-month-old boy with Bartter syndrome who presented with poor weight gain and an abdominal mass.

Background: Two Bartter syndrome phenotypes have been described, and molecular analyses demonstrate mutations in 1 of 3 genes encoding ascending limb of Henle transporters. We report phenotypic observations in 5 African American children with Bartter syndrome in the context of a distinct genotype. Methods: Mutation analyses were performed in 5 unrelated African American children with Bartter syndrome. These results were correlated to clinical and laboratory data. Calcium metabolism was evaluated with a bone disk bioassay. Results: Mutation analyses demonstrated homozygous deletion of the ClC-Kb gene in all children. Two children had polyhydramnios and premature birth; the others were born at term and presented with failure to thrive or dehydration. All receive indomethacin, spironolactone, and potassium chloride with improved but borderline hypokalemia. Growth has improved with therapy, but height SD scores range from -3.9- to -1.4. Urinary calcium excretion is normal, and bone disk bioassay shows no abnormal calciotropic activity. No patient had nephrocalcinosis, but renal sonograms show loss of corticomedullary differentiation. Conclusions: African Americans with Bartter syndrome genotyped to date have homozygous deletion of ClC-Kb . Clinical observations in our patients include partial correction of hypokalemia and suboptimal growth despite therapy. Abnormal calciotropic activity and nephrocalcinosis are not seen, but renal ultrasounds are abnormal. (J Pediatr 2001;139:105-10)

For values in the normal pediatric range, endpoint modifications of the Jaffé method for measuring plasma creatinine (PCr) yield higher results than other commonly used techniques. In an effort to evaluate the Olympus AU5000 endpoint method used by the large reference laboratory to which many of our patients are directed by their third-party payor, we compared results with a kinetic Jaffé technique using paired samples from the same specimens. In 46 samples, the kinetic method measured Pcr ator =0.8 mg/dl, whereas the endpoint technique PCr was higher by 0.1 mg/dl in 6 (13%), 0.2 mg/dl in 23 (50%), and 0.3 mg/dl in 16 (35%) samples (P0.0001). The combination of these higher values and the same reported normal range for all children ages 2-12 years (0.3-1.0 mg/dl) and 13-17 years (0.7-1.4 mg/dl) makes interpretation of Olympus AU5000 endpoint method results difficult, particularly for younger children. The results reinforce the need for each laboratory to provide comprehensive age- and sex-adjusted normal PCr ranges.

UNDERESTIMATION OF GLOMERULAR FILTRATION RATE (GFR) IN CHILDREN USING SERUM CREATININE (Scr) VALUES MEASURED IN A COMMERCIAL LABORATORY (CL) VS A CHILDREN'S HOSPITAL LABORATORY (CHL). 2185

The convective aspects of pediatric peritoneal dialysis (PD) -fluid transfer with its attendant solvent drag -were evaluated in vivo in 8 children on maintenance PD. The evaluation was performed according to the mass transport model of pyle. Reflection coefficients were calculated for urea, creatinine, uric acid, glucose and idealized total protein. These values were compared to adult means. There were no differences in reflection coefficients, except for total protein, which had a lower value. Maximum ultrafiltration rates were also calculated for the three commercially avail able dialysate glucose concentrations (1.5%, 2.5%, 4.25%). These values were scaled for body surface area to allow comparison with adult means. All values were lower than the adult means, but were not outside two standard deviations. Convective transport in PD in children over 1 Vl years of age, does not appear to be significantly different than that in adults. There are two components to solute removal in peritoneal dialysis: diffusion and convection. Convective transport, the passive movement of solute in a solvent stream across a semipernleable membrane, is directly related to the rate of ultrafiltration. The convective component of solute removal in peritoneal dialysis may be responsible for a significant per cent of transport of larger molecular weight solutes (I). Little infornlation is currently available concerning this aspect of pediatric peritoneal dialysis. Kohaut and Alexander have reported that it is more difficult to achieve ultrafiltration in infants than in older children, adolescents, and adults (2). The convective component of peritoneal dialysis in infants may therefore contribute less to overall solute removal than in older children and adults.

A 9 1/2-year-old female developed pneumatosis cystoides intestinalis (PCI) which was detected radiographically 4 1/2 months after transperitoneal cadaveric renal transplantation, during a period characterized by recurrent episodes of acute rejection. Radiographic evaluation was prompted by the development of cramping abdominal pain, distention, and tenderness localized to the region of the allograft, which occurred during one such episode. Pneumatosis was localized primarily to an area of colon that lay in direct contact with the allograft. Evaluation of the available clinical and roentgenographic evidence suggested that pneumatosis may have resulted from the development of a sympathetic inflammatory reaction within the bowel wall adjacent to the acutely inflamed allograft. Subsequent stabilization of renal function was associated with resolution of the pneumatosis over the ensuing 8 months without surgical intervention or additional medical therapy.

Acute renal failure (ARF) may be defined as a symptom complex that occurs when body fluid homeostasis is impaired by the rapid loss of kidney function. The diagnosis and pathophysiology of ARF are considered elsewhere in this volume. The past few decades have brought about major advances in the treatment of the biochemical derangements, hypertension, and fluid imbalance associated with acute renal failure. With widespread availability of dialysis, mortality has markedly decreased; those deaths that do occur are related more to the primary disorder and its complications than to renal failure. Therapy for acute renal failure depends upon the nature or the degree of renal impairment.

Even though multiple mechanisms operate to maintain the serum sodium concentration within a narrow range, serum sodium concentration is frequently abnormal in hospitalized children. This article defines terms clinically useful in categorizing such disorders and provides an overview of the physiology of sodium and water homeostasis. The recognition and treatment of disorders associated with an abnormal serum sodium are then considered.

Severe hypertension and hypertensive emergencies in children most often occur in association with secondary forms of high blood pressure and may develop in children with previously unrecognized disease or as a sudden change in children with known hypertension. The term hypertensive crisis or hypertensive emergency is used to denote a clinical situation in which the blood pressure has been elevated for some period of time and ought to be lowered over minutes, or hours depending on the patient’s clinical status. The clinical presentation of hypertensive emergencies varies. Life threatening hypertensive symptoms, such as acute heart failure, pulmonary edema or neurologic changes require immediate lowering of the blood pressure. (Table I)

Symptomatic hypotension complicated 53-87% of all treatments in 7 of our pediatric HD patients (HDP) despite modest ultrafiltration ( .40), nor were the observed disturbances attributable to differences in resting HR, supine mean arterial pressure,months on dialysis, or age. The data indicate that AD occurs commonly among pediatric DP. The observed pattern of disturbances is consistent with defective cardiac parasympathetic innervation, with HDP more severely affected than PDP. AD also may be 'unmasked' more readily in HDP, since the higher ultrafiltration rates associated with HD require more effective cardiovascular reflex compensation. AD should be considered as a possible cause of recurrent, symptomatic hypotension in pediatric DP.

Transplantation remains the optimal replacement therapy for children with end stage renal disease. Cadaveric allograft survival (surv)has improved over the past decade. We reviewed our experience with 61 first cadaveric transplants performed from 1972 through 1982. Twenty-three recipients(38%)were female and 38(62%) were male;the mean age was 11.2 yrs.(range 2-19). Forty-two (69%) were white,18(29%)black,and 1(2%)hispanic. Thirty-five(57%)had received at least 5 random donor blood transfusions(trans). Thirty (50%)were matched for a minimum of 2 HLA A and B antigens (Ag). Proportional hazards analysis(Cox's model)was used to examine 5 explanatory variables:sex,age,race, ≥5 trans,and number(no.)of Ag matches. Sex,age,and race did not affect graft surv. In this population,trans alone did not improve transplant surv(p>0.2).The no. of Ag matches was positively correlated with graft surv.(B=-0.3, p

Significant protein loss through the peritoneum of children on peritoneal dialysis(PD)has been well documented. To investigate this phenomenon,8 children(mean age 10yrs,range 1-19)were studied. A single 8-hour isotope-labelled exchange was performed and timed dialysate samples were obtained. Data were analyzed by the model of Pyle. The model determines the diffusive and convective characteristics of the peritoneum:the mass transfer area coefficient (MTAC)and the reflection coefficient(RC). The MTAC is an area permeability product(ml/min)and the RC is the fraction of solute reflected at the membrane during the convection associated with ultrafiltration. The mean(±SD)MTAC and RC for urea were 17.7±7.9 ml/min/1.73m2 and 0.14±0.08 respectively,for creatinine 11.6±7.0 and 0.28±0.01, for uric acid 7.7±3.9 and 0.44±0.16, for glucose 9.4±2.9 and 0.49±0.17, and for idealized total protein(T.P.)0.12±.15 and 0.95±0.03. When compared with adult means, excepting T.P., these were not statistically significant. The MTAC for T.P. was larger than in adults(p