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The aim of this study is to introduce a method for estimating the population of a Middle Eastern city, the city of Hillah, in the absence of a census which was last conducted in 1997. The method incorporates the normalized difference built-up index and land use-land cover information to identify residential areas for four years 1987, 1997 (the last census), 2008, and 2018 using Landsat imagery. Dasymetric mapping is employed to rezone residential pixels to the city's administrative districts or mahallahs. Mahallah populations for each year are estimated using local and historical urban morphology characteristics combined with standardized housing and household sizes. The result of this study is a range of estimates for mahallah populations, but a reasonable estimate of the city of Hillah's population is developed. The use of historical information, urban design, and environmental data with remote sensing methods in a Middle Eastern context provides an added tool in the arsenal of population estimation techniques.

Particulate matter (PM) contributes to an increased risk of respiratory and cardiovascular illnesses, cancer, and preterm birth complications. This project assessed PM exposure in Eastern Indonesia's largest city, where air quality has not been comprehensively monitored. We examined the efficacy of wearing masks as an individual intervention effort to reduce in-transit PM exposures. Handheld particulate counters were used to investigate ambient air quality for spatial analysis, as well as the differences in exposure to PM2.5 and PM10 (μg/m(3)) by different transportation methods [e.g. motorcycle (n=97), pete-pete (n=53), and car (n=55); note: n=1 means 1m(3) of air sample]. Mask efficacy to reduce PM exposure was evaluated [e.g. surgical masks (n=39), bandanas (n=52), and motorcycle masks (n=39)]. A Monte Carlo simulation was used to provide a range of uncertainty in exposure assessment. Overall PM10 levels (91±124 μg/m(3)) were elevated compared to the World Health Organization (WHO)'s 24-hour air quality guideline (50 μg/m(3)). While average PM2.5 levels (9±14 μg/m(3)) were below the WHO's guideline (25 μg/m(3)), measurements up to 139 μg/m(3) were observed. Compared to cars, average motorcycle and pete-pete PM exposures were four and three times higher for PM2.5, and 13 and 10 times higher for PM10, respectively. Only surgical masks were consistent in lowering PM2.5 and PM10 (p

People living in slums can be considered left behind with regard to national successes in achieving Millennium Development Goals (MDGs). The objective of this study was to evaluate the living and working conditions of waste pickers and their children in a landfill slum located in the largest city in eastern Indonesia. A total of 113 people from the landfill slum and 1184 people from the general population participated in face-to-face interviews. Municipal solid waste (MSW) was analyzed for metals, metalloids and fecal indicator bacteria. Ambient air quality including particulate matter was measured in the landfill. Households in the landfill slum were 5.73 (p=0.04) times more likely to be below the international poverty line (MDG 1: Poverty) and 15.6 times (p0.01) more likely to have no one in the household possessing a primary education (MDG 2: Universal Education), and 107 times (p0.01) more likely not to have improved sanitation facilities (MDG 7: Environmental Sustainability) when compared to the general population. Diarrhea is one of the leading causes of death in children under five in Indonesia. Young children living in the landfill slum were 2.87 times (p=0.02) more likely to develop diarrhea than their general population counterparts. Other survey results and environmental measurements suggest that landfill slum children have additional adverse health effects (e.g. infections and poisoning). Poverty underlies several MDG issues that directly or indirectly affect child health. Therefore, eradicating extreme poverty will continue to be the most critical challenge for the MDGs beyond 2015.

This pilot study evaluated the potential effect of household environmental factors such as income, maternal characteristics, and indoor air pollution on children’s respiratory status in an Eastern Indonesian community. Household data were collected from cross-sectional (n = 461 participants) and preliminary childhood case-control surveys (pneumonia cases = 31 diagnosed within three months at a local health clinic, controls = 30). Particulate matter (PM2.5 and PM10) was measured in living rooms, kitchens, children’s bedrooms, and outside areas in close proximity once during the case-control household interviews (55 homes) and once per hour from 6 a.m. to midnight in 11 homes. The household survey showed that children were 1.98 times (p = 0.02) more likely to have coughing symptoms indicating respiratory infection, if mothers were not the primary caregivers. More children exhibited coughing if they were not exclusively breastfed (OR = 2.18, p = 0.06) or there was a possibility that their mothers were exposed to environmental tobacco smoke during pregnancy (OR = 2.05, p = 0.08). This study suggests that household incomes and mother’s education have an indirect effect on childhood pneumonia and respiratory illness. The concentrations of PM2.5 and PM10 ranged from 0.5 to 35.7 µg/m3 and 7.7 to 575.7 µg/m3, respectively, based on grab samples. PM was significantly different between the case and control groups (p &lt, 0.01). The study also suggests that ambient air may dilute indoor pollution, but also introduces pollution into the home from the community environment. Effective intervention programs need to be developed that consider multiple direct and indirect risk factors to protect children.

This study evaluated multiple factors that may contribute to an increased risk of childhood diarrhea in eastern Indonesia. Mothers with at least one child under the age of 5 years (n = 303) were interviewed face-to-face in two sub-districts of a large city in eastern Indonesia. Results showed that children were 4.72 times more likely to develop diarrhea if mothers washed their hands without soap after defecation (95% confidence interval (CI) 1.22–18.3; p = 0.03), 3.83 times more likely if households had no access to improved sources of drinking water (95% CI 1.12–13.1; p = 0.03), and 3.21 times more likely if households had income levels below $152/month (95% CI 1.40–7.35; p

After 30+ years of clinical practice, it is this author's experience that adrenal fatigue is a common stress-related disorder in which the symptoms are strongly influenced by circulating cortisol levels. Although adrenal fatigue has appeared in the medical literature by various names for over 100 years, its prevalence is just now coming to the forefront. Healthcare professionals can make a dramatic difference by monitoring patients' health to check for signs and symptoms of adrenal fatigue. Despite the frequency with which this health condition occurs, even many skilled clinicians have not had the opportunity to learn about it or its importance to their practice. The intent of this article is to provide the practitioner with clinically relevant information about the diagnosis and successful treatment for adrenal fatigue.

The later life migration literature includes analyses of migration streams, examination of later life migration precursors, the economic impact of migration, and meta-analyses advocating methodological refinement. Missing are studies of later life migrants post relocation, including their social integration in receiving communities. The small area analysis presented here evolved in consultation with a local Planning Committee including older adults and service providers that guided development of an aging services plan for Dare County on the North Carolina Outer Banks. Multiple methods were applied, including secondary historical and contextual data, in-depth interviews, and a brief survey of older adults using services. Findings suggest difference among communities in the integration of later life migrants with older natives that provides context for service needs and delivery. Community difference stems from topographical land form characteristics, socioeconomic and cultural difference between later life migrants and older natives, and the course of residential development across communities.

Pine Hill lies near the center of a gabbrodiorite intrusion in the foothills of the Sierra Nevada mountain range in El Dorado County, CA, USA. We assembled an extensive flora, examined the distribution and associations of vascular plant taxa, and specifically focused on associations of six rare plant taxa. The influence of environmental variables on plant distribution was investigated using a stratified random plot sampling technique and applying canonical correspondence analyses. The site contained over 10% (741 plants) of the flora of the entire state of California including seven rare species. Species segregated into chaparral, oak woodland, and grassland communities. In chaparral and woodland, and on serpentine sites, over 75% of the flora was comprised of native species. The non-serpentine grassland community was dominated by exotic species (64% exotic) and contained no rare species. Shrub and tree cover were the most important biotic factors associated with plant species distribution; serpe...

ealth-related data are used at many geographic and political levels by individuals and groups for a multitude of purposes. The focus of this paper is on what and how data are used at the local level, for what purposes and by whom, as well as some of the unique challenges and methodological manipulations involved. Examples of common and unique uses of data and the analytic challenges involved are included. Health-related data are typically used at the local level to describe populations in terms of demographics, economics, social and environmental conditions, disease prevalence, births, causes of deaths, health behaviors, and available health care resources. They may also be used to characterize access to health services and the use and cost of such services. The data are generally secondary, ie, obtained from another agency that specified form and content without local user input. The data may come from the US Census (eg, income, housing, education), the state and federal vital statistics system (eg, births, deaths, communicable disease incidence), disease registries (eg, cancer incidence, prevalence), or national or state surveys (eg, Behavioral Risk Factor Surveillance System). Other sourcesmaybeagenciesresponsibleforMedicaid,Medicare, licensing and regulation, environmental protection, education, commerce, agriculture, transportation, highway safety, or law enforcement. With increasing technology and governmental investments in data collection, there is a wealth of data available, but they may not be readily useful to or easily analyzed by the local user. Local Users and Uses The users of health-related data at the community level in North Carolina might be local chapters of voluntary health organizations (eg, American Heart Association, American Lung Association), Healthy Carolinians groups, hospitals, health departments, health care providers, professional associations, academic institutions, news media, governmental agencies, elected officials, and individual citizens interested in their own health or the health of their family and community. Typical purposes for data use include community diagnosis, program planning, policymaking, advocacy, justification of requests for resources, and program evaluation. The purposes may be categorized within the 3 core functions of public health (ie, assessment, policy development, and assurance) 1

Due to the presence of gross magnetic susceptibility artifacts, functional MRI (fMRI) has proved problematic in studies of the human inferior frontal cortex (IFC). There is a strong desire, therefore, to employ techniques that mitigate susceptibility artifacts in the IFC while preserving the imaging parameters of an fMRI study. It has been shown that the use of a single, strongly diamagnetic, intra-oral passive shim significantly improves the homogeneity of the static magnetic field (B0) and, as a result, alleviates the susceptibility artifacts within the IFC. In this study, practical issues regarding the use of an intra-oral passive shim are examined. We investigated B0 instabilities within the IFC resulting from subject head motion in order to calculate the effects of an intra-oral passive shim on the temporal variance of an EPI time series. These studies show that the addition of an intra-oral passive shim improves both B0 homogeneity and signal stability, and increases sensitivity to functional activation. Magn Reson Med 50:1089–1094, 2003. © 2003 Wiley-Liss, Inc.

DISEASE MAPS: Epidemics on the Ground. By Tom KocH. ix and 330 pp.; maps, ills., bibliog., index. Chicago: University of Chicago Press, 2011. $45.00 (cloth), ISBN 9780226449357. What more can be said about the history of disease mapping? Tom Koch answers this question with his latest work, Disease Maps: Epidemics on the Ground. This effort extends the author's earlier foray into this subject with Cartographies of Disease: Maps, Mapping, and Medicine (2005), which emphasized the disease map as an argument for or against theories of disease causation. Disease Maps sets out to examine the historical conceptualizations of disease at every scale of "seeing" (p. 4) by peeling away the historical and philosophical layers interposed between today's digital disease maps and their pen-and-ink forebears. Koch thus reveals the evolving relationships among cartography, medicine, and disease. Koch's overarching approach is to march the reader through the centuries, bearing witness to changing disease concepts and on-the-ground cartographic representations of public health events. Beginning with the sixteenth century and moving to the near present, this progression is marked by such iconic diseases as plague, yellow fever, malaria, cholera, typhoid, polio, and cancer; wherein the reader is introduced to individuals, ideas, and paradigms salient to both the social construction of disease and disease maps. For example, Koch compellingly draws together the sixteenth-century anatomical and cartographic works of Vesalius and Ortelius as the fundamental impetus in the development of the disease map. Vesalius's anatomical atlas, De Humani Corporis Fabrica (1543), and Ortelius's geographical atlas, Theatrum Orbis Terrarum (1570), began a new way of seeing the internal and external worlds of the human body and geographical space. These consilient works were important as first steps in the systematization of knowledge in human anatomy, disease, and geography that ultimately led to disease mapping. Later the reader is introduced to the eighteenth-century medical luminary Thomas Sydenham (1624-1689), whose revolutionary disease-classification system paved the way for associating disease symptoms with underlying physical and social environmental factors. In the mid-nineteenth century the physician William Farr (1807-1883) entered the stage, promoting the more sophisticated use of vital statistics to locate, graph, and map excess mortality. The work of Farr and his contemporaries gave rise to national-level programs and institutions concerned with the systematic collection of data on vital statistics and the development of national registries. Koch brings to light an impressive array of known and lesser-known individuals and their contributions to the discipline of disease mapping. Even though his arguments fascinate the reader, however, they do not consistently develop and link historical cartographic and scientific practices to twenty-first-century GIS and analyses of geographical patterns of disease. Koch does see the disease map as a document laden with contemporary scientific thinking, but he is selective in the choice of important natural philosophers he discusses as having been participants in the unfolding narrative. Early on, two well-known seventeenth-century philosophers are brought onto the stage. Here, Robert Boyle (1627-1691) represents laboratories and experimentation with results to be judged and validated by authoritative peers, whereas Thomas Hobbes (1588-1679) represents careful observation, logic, and discernment to arrive at the truth (pp. 69-70). In other words, a dualism is created between two reasoning modes in science: deduction and induction, with the former rising to primacy in scientific thought. This distinction comes to the fore in Koch's discussion of how John Snow (1813-1858) used maps to demonstrate the waterborne nature of cholera transmission. Otherwise, the connection between these two reasoning modes and eighteenth- and nineteenth-century attempts at understanding the etiology of disease are not apparent. …

Introduction A paucity of work force planning literature exists for hand therapy services. Purpose This descriptive study aimed to map the geographical distribution of US Certified Hand Therapists (CHTs) and describe characteristics of US populations living in respective CHT workplace Zip Code Tabulation Areas (ZCTAs). Methods A de-identified Zip Code list of all active CHTs through April 2016 from the Hand Therapy Certification Commission, included 5572 CHTs with US ZCTAs. The CHT ZCTAs were matched with population parameters “rurality”, “poverty” and “race and ethnicity” from the 2010 US Census and 2014 American Community Survey. Results The 5,572 CHTs practice ZCTAs mostly overlapped with high density US population areas, covering just 9% of the total number of 33,120 US ZCTAs. The population in CHT ZCTAs was 1) urban in nature, 2) with lower poverty rates than ZCTAs without CHTs, and 3) mostly reflecting US race and ethnicity population distribution. Only 3.7% of CHTs worked in large concentrations of 11 to 26 CHTs per ZCTA near or in urban centers. Most CHTs, 67%, worked in one to three CHTs per ZCTA concentrations, contributing to a larger geographic spread of CHT locations than expected. Discussion and Conclusion This study provides a foundational snap shot of the distribution, the potential availability, of the 2016 CHT workforce in the context of US population characteristics. It may serve as baseline for supply and demand studies and interventions to grow the CHT profession and optimize the distribution of CHTs to better meet population needs.

To determine the reliability of videoconferencing technology in evaluating skin tumors, the impact of the technology on the clinicians' degree of suspicion that a skin tumor is malignant, and the recommendation to do a biopsy.Four skin cancer screenings were conducted at rural health care facilities in eastern North Carolina that were connected to East Carolina University School of Medicine. A dermatologist saw the patients in person at the local facility, and the same patient was seen by a dermatologist via a T-1 connection to Greenville, North Carolina.The two physicians were in absolute agreement on 59% of the 107 skin tumors evaluated. There were five lesions identified by the on-site dermatologist as a probable or definite malignancy. The degree of concern about a lesion being malignant and the decision whether to do a biopsy were not significantly different, as shown by kappa analysis.The concern about the malignancy of a particular skin lesion and the recommendation whether to do a biopsy were not significantly affected by telemedicine technology.

This user's manual describes the capabilities of the Force Oriented Cost Information System (FOCIS) model and how it is used to develop, evaluate, and track multi-year defense program plans. FOCIS operates on personal computers running Microsoft XP or any currently existing later operating system (VISTA or Windows 7). FOCIS operates as a standalone application or in an existing local area or wide area wired or wireless network. The foundation of FOCIS is a user-entered, unit-level force structure database that can be modified to reflect alternative defense planning strategies. FOCIS provides cost estimating functions to estimate the costs of the program plans. FOCIS also provides a suite of integrated analysis tools that allow users to evaluate program resources using common defense analysis models that can be constructed as combinations of missions, military functions, geographic locations, and other taxonomies deemed useful. FOCIS gives a country's defense planners the ability to understand the total cost of alternative program plans, to determine whether they are affordable and to understand how their resources are being used relative to national defense priorities.

More than a trillion dollars of public money is spent annually on health care in the United States. In order to inform policymakers, health advocacy groups, tax-paying constituents, and beneficiaries, it would be useful to present and analyze health outcome and health-related data at the U.S. congressional district level. Presently, health event data are not reported at this political unit; however, recent interest and advances in areal interpolation techniques are beginning to transcend the inherent limitations imposed by legacy data collection and analyses systems. In this paper, the authors use the dasymetric approach to illustrate how this areal interpolation technique can be used to transfer county-level mortality rate data from several causes of death to the U.S. congressional district level. The study’s primary goal is to promote areal interpolation techniques in the absence of a systematic and comprehensive national program for geocoding health events.

Smallpox mortality from an early 19th century epidemic in Finland is mapped at the parish village level. First, geographically referenced historical materials are used to construct a map showing the spread of smallpox mortality among villages. Next, the diffusion of smallpox morbidity is simulated by computer for the same set of villages. These two maps are then compared. Results indicate that at this scale maps of mortality diffusion can show general trends but have no direct spatial correspondence to the underlying pattern of morbidity diffusion. Mortality maps cannot be used as a surrogate measure of infectious contact behavior at micro scales of analysis.

Imaging the human orbitofrontal cortex (OFC) with fMRI is problematic due to the proximity of this region to the air-filled sinuses, which causes susceptibility artifacts. Placing a strongly diamagnetic material into the mouth ('mouthshim') of a human volunteer can significantly reduce the artifacts in this region. Using the same combined olfactory and visual fMRI paradigm, we compared brain activation and static B0 field maps of participants being scanned both with and without the 'mouthshim'. Results demonstrate that the device improves the B0 field homogeneity within OFC, resulting in significantly stronger BOLD activation in this region. However, the device also caused both increased head motion and reduced activation in insular cortices due to more frequent swallowing and tactile stimulation of the tongue. The 'mouthshim' should only, therefore, be used where sensitivity in OFC regions is paramount.

Inhomogeneous magnetic fields produce artifacts in MR images including signal dropout and spatial distortion. A novel perturbative method for calculating the magnetic field to first order (error is second order) within and around nonconducting objects is presented. The perturbation parameter is the susceptibility difference between the object and its surroundings (for example, approximately 10 ppm in the case of brain tissue and air). This method is advantageous as it is sufficiently accurate for most purposes, can be implemented as a simple convolution with a voxel-based object model, and is linear. Furthermore, the method is simple to use and can quickly calculate the field for any orientation of an object using a set of precalculated basis images.

Background Choosing between actions associated with uncertain rewards and punishments is mediated by neural circuitry encompassing the orbitofrontal cortex, anterior cingulate cortex (ACC), and striatum; however, the precise conditions under which these different components are activated during decision-making cognition remain uncertain. Methods Fourteen healthy volunteers completed an event-based functional magnetic resonance imaging protocol to investigate blood-oxygenation-level-dependent (BOLD) responses during independently modeled phases of choice cognition. In the “decision phase,” participants decided which of two simultaneous visually presented gambles they wished to play for monetary reward. The gambles differed in their magnitude of gains, magnitude of losses, and the probabilities with which these outcomes were delivered. In the “outcome phase,” the result of each choice was indicated on the visual display. Results In the decision phase, choices involving large gains were associated with increased BOLD responses in the pregenual ACC, paracingulate, and right posterior orbitolateral cortex compared with choices involving small gains. In the outcome phase, good outcomes were associated with increased BOLD responses in the posterior orbitomedial cortex, subcallosal ACC, and ventral striatum compared with negative outcomes. There was only limited overlap between reward-related activity in ACC and orbitofrontal cortex during the decision and outcome phases. Conclusions Neural activity within the medial and lateral orbitofrontal cortex, pregenual ACC, and striatum mediate distinct representations of reward-related information that are deployed at different stages during a decision-making episode.

At higher static magnetic field (B(0)) strengths (>/=3 T), the study of human inferior frontal cortex (IFC) when utilising a variety of MRI techniques is severely hampered by the presence of susceptibility artifacts. This is particularly the case for blood oxygenation level-dependent functional MRI, where large signal voids are generally encountered in the frontal lobes. A previous study described an approach to artifact correction involving a mouth insert consisting of a prototype diamagnetic passive shim [Magn. Reson. Med. 48 (2002), 906]. Here we extend that method by investigating the effect of five different intraoral passive shims on B(0) homogeneity and echoplanar imaging susceptibility artifacts within the brain, and particularly the IFC, of six subjects. The optimal passive shim is shown to be subject- and study-specific, providing an average reduction in mean absolute B(0) offset within the IFC of 57%, along with a concomitant reduction in echoplanar susceptibility artifact. All subjects were at ease while wearing the intraoral shims. A 4-min in vivo protocol to determine the optimal passive shim from the available set, utilising intrinsic structural and B(0) subject data, is described and shown to be accurate and reliable.

The use of detached endcaps for 3 T birdcage coils was investigated both theoretically and experimentally. Finite difference time domain analysis, along with workbench and MRI techniques, were used to map the radiofrequency (RF) B1 distribution along the coil axis with and without an endcap. Without an endcap the measured B1 value at the service end of the birdcage was only 45% of the value at the coil’s center. This was improved to 85% with a detached endcap of maximum achievable diameter (375 mm), positioned 4 mm from the RF shield. The B1 field distribution on the patient side of the coil was unaffected by the presence of the endcap. The dependence of the B1 distribution as a function of endcap diameter was also investigated. Surprisingly, simulations and experiments show that there is an optimum ratio of endcap-to-birdcage coil diameter (1.08) that gives the best B1 homogeneity. In the human head the optimized endcap, positioned 16 mm from the RF shield, improves the MRI signal amplitude from 55% to 85% of maximum toward the service end. This novel endcap design is easy to implement with existing birdcage coils, and could prove useful when flexibility in access to the RF coil is required. Magn Reson Med 49:363–370, 2003. © 2003 Wiley-Liss, Inc.

The aim of this novel technique is to allow researchers, particularly those operating at high static magnetic field strengths on fMRI applications, to tailor the static magnetic field within the brain. The optimum solution for their experimental needs is reached, utilizing the full potential of the active shims at their disposal. The method for shimming human brain, which incorporates automatic brain segmentation to remove nonbrain tissue from the optimization routine, is presented and validated. The technique is fast, robust, and accurate, achieving the global minimum to a static field homogeneity function of the in vivo brain. Both global and specified local regions of the brain can be selected on which to optimize the shims without requiring skilled intervention. The effectiveness of the automated local shim is demonstrated in an olfactory fMRI study where significant activations in the orbitofrontal cortex were very clear when the above method was employed.

OBJECTIVES: This study examined premature mortality by county in the United States and assessed its association with metro/urban/rural geographic location socioeconomic status household type and availability of medical care. METHODS: Age-adjusted years of potential life lost before 75 years of age were calculated and mapped by county. Predictors of premature mortality were determined by multiple regression analysis. RESULTS: Premature mortality was greatest in rural counties in the Southeast and Southwest. In a model predicting 55% of variation across counties community structure factors explained more than availability of medical care. The proportions of female-headed households and Black populations were the strongest predictors followed by variables measuring low education American Indian population and chronic unemployment. Greater availability of generalist physicians predicted fewer years of life lost in metropolitan counties but more in rural counties. CONCLUSIONS: Community structure factors statistically explain much of the variation in premature mortality. The degree to which premature mortality is predicted by percentage of female-headed households is important for policy-making and delivery of medical care. The relationships described argue strongly for broadening the biomedical model. riginally published American Journal of Public Health Vol. 89 No. 6 June 1999

This volume is a compilation of papers relative to paleokarst and associated reservoirs. The examples illustrate many of the rock types, and stratigraphic, structural, and paleotopographic features of carbonate strata which result chiefly from solution and collapse due to ingress of meteoric waters at and below unconformities. Examples presented here range from settings with considerable dissolution and collapse to those with significant unconformities but little evidence of meteoric alteration. It is estimated that 20–30% of recoverable hydrocarbons are in some way related to unconformities. Paleokarst reservoirs may also be important future reservoirs for application of horizontal drilling technology.

The Egyptian Defense Forces Cost Model is a program created by IDA for estimating total investment and operating costs of alternative structures for Egyptian defense forces. Using actual 1991 costs and characteristics as a baseline, the model projects annual costs through 1998. The manual serves as both a user's guide and a maintenance manual for the model.

The syndrome of megacystis-microcolon-intestinal hypoperistalsis has been reported in a total of seven female infants. Massive abdominal distention secondary to a distended urinary Fig 1. Plain film of markedly distended abdomen with no air beyond stomach. Stomach is displaced upward toward left. der was the major presenting characteristic. Iutestinal hypoperistalsis, apparent in the early neonatal period, persists without improvement. Exploratory laparotomy reveals malrotation and malfixation of a small microcolon. No anatomic cause of intestinal or bladder obstruction can be found. Intestinal and/or rectal biopsy specimens contain abundant ganglion cells and nerve fibers. The outcome has been uniformly fatal, with survival in the reported cases ranging from two days to 34 months.

I am glad to write you a note in support of my opinion that the time has come to increase the required pediatric training in hospitals for Board certification in Pediatrics from 2 to 3 years. I must state at the beginning that I don't believe that one can advocate this increased requirement as a necessity in absolute terms. The whole concept of the desirability of Board certification in any field has been challenged repeatedly, although I believe any objections that have been raised to such organizations apply less to pediatrics than to any other program. American children, in my opinion, are immensely better off due to the establishment of the Board of Pediatrics and the Academy of Pediatrics.

Summary We report a group of four infants and one child who showed a strikingly similar syndrome characterized by persistent dehydration, acidosis with hyperchloremia, and extensive diffuse deposits of calcium salts in and around the renal tubules.

The Health of the Nation Depends on the Health of the Child The number one health problem of this country is not any one aspect of medical care. Cancer, heart disease, mental illness, important in themselves, are less vital to the nation's well-being than the general health of its children. Organic and mental health of adults depend largely on the care they received as children. Only in old age is the incidence of disease as high as in childhood; in no other age group does disabling disease strike as often. In infancy the very survival rate varies directly with the availability and quality of medical care. The need for preventive, diagnostic, and curative services of high quality for all children has beenn established and agreed upon by the government, organized medicine, voluntary agencies and the public. Furthermore, there is general agreement on the need for improvement of child health. So much evidence has already been givn on the subject that the case for better medical care and health supervision for children is well established. Better Child Health Depends on More Well-Trained Doctors How is better medical care for children to be achieved? In the last analysis, success in this field depends not so much upon the physical facilities of the hospital, the laboratory or the pharmacy as upon the judgment and skill of the individual physician. This skill is a result of training and experience. Deficiencies in Pediatric Training As a step toward better and more evenly distributed health services for children the American Academy of Pediatrics has conducted a nation-wide study of all factors involved in the medical care of children in the United States—hospitals, community health services, private practice of physicians and dentists, and pediatric education. The preliminary findings of the Study reveal a startling lack of adequate training of a considerable portion of both general practitioners and pediatricians.

A study was made of the development of chemical homeostasis in the newborn infant. In a series of 43 essentially healthy, full term, newborn infants, serial determinations during the first day of life of blood pH, plasma CO2, chloride and total base content, and serum protein were made. Comparison with similar data on premature infants and adults is presented. Most full term infants at birth are in a state of metabolic acidosis with a lowered blood pH and plasma CO2 content, but have essentially normal plasma chlorides and total base values. The majority of these infants within a few hours have a blood pH of adult level but maintain for some time a lowered CO2 content.

Summary 1. One hundred and seventy-seven children were given a sulfonamide drug during two or more courses and had no reaction during the first course. Eighty-six were given sulfathiazole; three developed febrile reactions, none within the first forty-eight hours. Ninety-one were given sulfadiazine; four developed febrile reactions, only one within the first forty-eight hours. 2. In the total of seven cases (4 per cent) exhibiting reactions tothese two drugs, fever appeared first on the second, third, fourth, fifth, seventh, fourteenth, and fifteenth days, respectively. It is suggested these febrile responses were toxic reactions to the drug that might have occurred at any time and had no clear relation to previous drug therapy. 3. Two of the seven children with initial reactions were given botha second and a third course of the drug without reaction. 4. An “immediate” type of febrile reaction occurred during a secondcourse of sulfonamides in three of five children who had had reactions during a first course. 5. Our studies show that “sensitization” to sulfathiazole or sulfadiazineis not common or frequent in children, but that the occurrence of one reaction greatly increases the probability of future reactions. 6. Children who developed toxic symptoms during the first administration of the drug should be given the drug only with caution and close observation.

A study of the acid base balance of arterial blood in 92 premature infants, aged 1 to 65 days and 1.1 kg. to 2.3 kg. in weight, has been presented. The temporal artery blood was analyzed for pH, plasma CO2 content, chloride, total protein, total base. Alveolar carbon dioxide tension (pCO2) and "R" were calculated. Acid base analyses on the femoral artery blood of 16 adolescent well boys were used as controls. The study reveals the following salient facts: There is a wide variation in the blood chemical findings between normal, well premature infants. In addition, repeat determinations upon the same infants revealed a more labile blood chemical picture than is found in older infants or adults. No premature infant had all fractions of the acid base balance within the adult normal range. The mean values for pH, CO2 content and protein were reduced in premature infants, while the mean values for total base, chloride, phosphate and "R" were elevated as compared to the values for the adult controls. The mean value for carbon dioxide tension was normal. Sixty-seven per cent of the premature infants had the chemical findings of an uncompensated metabolic acidosis; 13% had a normal pH and CO2 content; 10% had a respiratory acidosis, 7% had a respiratory alkalosis and 3% were unclassified. There was no statistical correlation of acid base values to birth weight or age or weight at the time of chemical sampling. There was no difference of acid base values in infants who had been transfused by blood or plasma and those infants who had never been given blood or plasma transfusions. By clinical examination alone, the nature of the acid base variations could not be anticipated in what we generally consider as well premature infants. There was no correlation between the variations of the acid base disturbance and the prognosis for life in these babies. The fact that most premature infants have an increased hydrogen ion concentration and an unstable acid base balance may be additional reasons why premature babies so easily develop severe acidosis when any stress occurs, whether it is improper feeding, infection, etc. The cause of the acidosis in premature infants has not been established. The theory that premature infants have a partial anaerobic metabolism with a decreased production of carbon dioxide is tenable but not established.

It seems to me that it is best this afternoon that I do not simply read to you the formal report of the Committee for Improvement of Child Health, since that has already been submitted to the Executive Board of the American Academy of Pediatrics, accepted by it, and will soon be published. I would rather spend this time to develop further the ideas that are stated there. I believe that whatever I say will represent the general consensus of the members of the Committee, but the formal expression of their views I leave, as I have said, to the printed report, and only I am responsible for the details of this afternoon's report. As information resulting from the Academy's Study of Child Health Services became available, and as we grew in our understanding of the problems involved, it became more and more apparent that this work of the Academy concerned with the health of our nation's children could not stop with the end of the survey without great loss, particularly to the Academy itself. It was clear that the Academy was being projected into a position of great influence and authority because of the completeness and uniqueness of the information which it had gathered, but that this position of authority, with the influence it might give us towards directing future activities regarding child health in this country, could soon be lost. Information such as we have obtained becomes quickly obsolete. Changes are going on constantly in our dynamic nation, and in a very short time any opinion which we might have based on this survey could be considered out-dated. It was apparent also that the demand for assistance by various organizations having common purposes with our own, the demand for technical and professional advice, would be greatly increased by the gradual dissemination of knowledge that would result from the survey and that we would be constantly approached for advice and for assistance, especially in the field of medical education with which the survey dealt most importantly. This idea was transmitted to the Executive Board. The result was ultimately the formation of the Committee for Improvement of Child Health.

The action of intra-artenal priscoline ® supported by oral therapy has been studied intensively in seventeen cases of peripheral vascular disease. From the cases observed we may state that the drug is a valuable adjunct in two types of cases, namely, refractory leg ulcers prior to the onset of gangrene or established soft tissue necrosis and vasospasm whether due to trauma, the symptom complex of scleroderma or ulceration due to arteriosclerosis, diabetes or chronic thrombophlebitis.

Summary The respirator in poliomyelitis should be used as a means of giving physiologic rest in early and moderate paralysis of the respiratory muscles. The dramatized use of the respirator as an emergency lifesaving machine has occurred at the expense of interest in its more prosaic, but perhaps more valuable, function as a splint for weakened respiratory muscles. The early signs of respiratory weakness are often undetected, and the patient is given either no respiratory treatment at all, or none until a degree of fatigue occurs which would be considered a sign of intolerable neglect, were the muscles those of the arms. No clear distinction is made by many physicians between the various causes of respiratory failure in poliomyelitis. The respirator is seldom of use except where the intercostal muscles or diaphragm are paralyzed. Most cases of “bulbar” poliomyelitis are not helped. Two new types of machines for artificial respiration are described and their different advantages discussed. It is suggested that a national coordinated program for the handling of respiratory paralysis in poliomyelitis be planned as the only practical manner of meeting this problem.