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Background Problem-based learning (PBL) offers a unique model of remote learning that resembles important facets of students’ future medical careers. The purpose of this study was to determine if online PBL was successful and to identify creative innovations and best practices of online learning in order to better prepare medical students for health care careers in the future. Methods The impact of implementing virtually delivered PBL sessions on student experience and performance in comparison to in-person PBL sessions was evaluated. A 4-point Likert scale question was used to investigate the effect of the transition to online PBL on the students’ PBL process experience. Student PBL process grades were measured on a scale of 5–10, where 5 is “needs substantial improvement” and 10 is “meets expectations”. PBL session grades were compared in one session before and one session after the transition to online PBL using a paired t-test. Data are presented as number of responses per category (percentage), or as a mean +/- standard deviation. Results Based on our experiences, we identified a successful transition to online PBL with no meaningful impact on students’ performance. We also identified several challenges to online PBL and how students demonstrated creative solutions to overcome these challenges. As a result of our experience, we identified several key factors as best practices of implementing online PBL to ensure a smooth transition from in-person sessions for both faculty and students, including extensive preparation, participation of support staff, availability of adequate internet services and equipment, and input from instructional technology and design personnel. Conclusion Successful student performance and experience, along with best practices learned from implementing virtual PBL, provide valuable tools for improving teaching and critical insight into the challenges faced, when preparing students for global health care changes in the future.

Objective To determine the efficacy of a 4-month school-based health, nutrition and exercise intervention on body fatness and examine possible effects of demographic and anthropometric covariates. Methods Height, weight, waist circumference and body composition were measured in a diverse population of 644 NYC middle school students (mean ± SD age 12.7 ± 0.9 years; 46% male; 38% Hispanic, 17% East Asian, 15% South Asian, 13.5% African American, 8.5% Caucasian, 8% other) during the fall and spring semesters. Year 1 participants (n = 322) were controls. Experimental participants (year 2, n = 469) received a 12-session classroom-based health and nutrition educational programme with an optional exercise intervention. Results Groups were demographically and anthropometrically similar. The intervention resulted in significant reductions in indices of adiposity (ΔBMI z-scores [-0.035 ± 0.014; p = 0.01], Δ% body fat [-0.5 ± 0.2; p

Background Elevated levels of alanine aminotransferase (ALT) are associated with obesity and are often a consequence of non-alcoholic fatty liver disease (NAFLD). The aim of the present study was to assess the relationship between ALT and risk factors for adiposity-related co-morbidities in a diverse population of middle school children. Methods We measured height, weight, body fatness (bioelectrical impedance), waist circumference, insulin sensitivity, phase 1 insulin release (acute insulin response following intravenous glucose), beta-cell function (acute insulin response corrected for insulin sensitivity), ALT, lipid profiles, and circulating concentrations of interleukin-6 (IL-6), C-reactive protein, adiponectin, and tumor necrosis factor-α (TNF-α) in a multi-ethnic/racial population of 106 middle school students (aged 11–14 years, 45 female) of varying body mass indexes (BMI). Results Alanine aminotransferase was significantly correlated with BMI, % body fat, fat mass, waist circumference, fasting insulin, insulin resistance, triglycerides, and was inversely correlated with high-density lipoprotein cholesterol in children, even though all values of ALT were “normal” (range of 4.0–33.0 U/L). ALT was significantly higher in males than females even when corrected for body fatness. Significant correlations with lipids and insulin resistance persisted even when adjusted for age, gender, and body fatness. Conclusion Even within the normative range, ALT levels were significantly correlated with anthropomorphic and biochemical risk factors for adiposity-related co-morbidities in youth. Therefore, because ALT is correlated with dyslipidemia, insulin resistance, and central fat distribution, it might also serve as a marker of risk for adiposity-related co-morbidities beyond NAFLD. 摘要 背景： 丙氨酸氨基转移酶（alanine aminotransferase，ALT）水平升高与肥胖相关，这通常是非酒精性脂肪性肝病（non-alcoholic fatty liver disease，NAFLD）的结果。这项研究的目的是在不同的中学儿童人群中评估ALT与肥胖相关合并症危险因素之间的关系。 方法： 我们在106名体重指数（BMI）不同的多种族/人种中学生人群（年龄为11–14岁，有45名女性）中测量了身高、体重、体脂（生物电阻抗）、腰围、胰岛素敏感性、1相胰岛素释放（静脉注射葡萄糖后的急性胰岛素反应）、β-细胞功能（校正胰岛素敏感性后的急性胰岛素反应）、ALT、血脂谱、循环中的白细胞介素-6（IL-6）、C-反应蛋白、脂联素以及肿瘤坏死因子-α（TNF-α）浓度。 结果： 在儿童中，ALT与BMI、体脂百分比、脂肪含量、腰围、空腹胰岛素、胰岛素抵抗、甘油三酯显著相关，并且与高密度脂蛋白胆固醇负相关，即使所有的ALT值都是“正常的”（范围为4.0–33.0 U/L）。即便校正体脂后，男性ALT仍显著高于女性。血脂与胰岛素抵抗之间存在显著的相关性，即便在校正年龄、性别与体脂之后。 结论： 在年轻人中，即使ALT水平处在标准范围，它仍然与肥胖相关合并症的人体测量学以及生化危险因素显著相关。因此，由于ALT与血脂异常、胰岛素抵抗以及中心性脂肪分布相关，所以除了NAFLD之外它还可以作为一个肥胖相关合并症风险的标志物。

Background/Aims:Sex steroids, such as estrogens, are known to influence endothelial function by their vasodilator action. The aim of this study was to study the relation of puberty and sex steroids with endothelial function using peripheral arterial tonometry (PAT). Methods: In 89 healthy school boys and girls, we determined height, weight, waist circumference, percent body fat, BMI, BMI z-score, blood pressure (BP), BP percentiles, lipid profile, insulin, and glucose levels after overnight fast. Estrone (E1), estradiol (E2), DHEAS and E1-sulfate were measured using ultrasensitive assays. Participants were divided into 3 pubertal groups on the basis of their estrogen levels: group 1 (Tanner stage I), group 2 (Tanner stages II–III), and group 3 (Tanner stages IV–V). Endothelial function was measured by Endo-PAT 2000® and expressed as PAT index. A higher PAT index represents a higher reactive hyperemia response. Results: The PAT index was lowest at 1.42 ± 0.44 (mean ± SD) in group 1 and significantly increased in group 2 at 1.71 ± 0.35 (p = 0.02) and group 3 at 1.92 ± 0.38 (p < 0.001). The PAT index correlated positively with E2, DHEAS and age. Conclusion: Enhancement of the PAT index was associated with an increment in Tanner stages. The changes in E2 and DHEAS levels may contribute to increasing endothelial response to shear stress or arterial blood flow.

PURPOSE To evaluate the impact of residency work hour limitations on pediatrics residency programs in New York State, and to learn lessons that can be used nationally with the implementation of the Accreditation Council of Graduate Medical Education's similar rules. METHOD A three-page questionnaire was mailed to all pediatrics residency program directors in New York. The questionnaire assessed methods used to accommodate the work hour limitations and perceptions of the limitations' effects. RESULTS Twenty-one program directors responded (68%). Only large programs used night floats and night teams to meet work hour requirements. Programs of all sizes and in all settings used cross coverage and sent residents home immediately post call. About half of the programs hired additional nonresident staff, usually nurse practitioners, physician assistants, and/or attendings. The most frequently reported effects were decreases in the amount of time residents spent in inpatient settings, patient continuity in inpatient settings, flexibility of residents' scheduling, and increased logistical work needed to maintain continuity clinic. A summary of advice to other program directors was "be creative" and "be flexible." CONCLUSIONS New York's pediatrics residency programs used a variety of mechanisms to meet work hour restrictions. Smaller programs had fewer methods available to them to meet such restrictions. Although the logistical work needed to maintain continuity clinic increased greatly, continuity and outpatient settings themselves were not greatly affected by work hour limitations. Inpatient settings were more affected and experienced much more in the way of change.

Aim: Advanced glycation end products (AGEs) and/or their receptors (RAGE) are significantly positively correlated with adiposity, inflammation, dyslipidemia, and insulin resistance in adults. However, the relationships between AGEs, RAGE, and adiposity-related comorbidites in children have not been well studied. Methods: In a cross-sectional study of 88 children (age 11-15 years) from the New York area enrolled in the Reduce Obesity and Diabetes (ROAD) study, we examined the correlation of the AGE Nε-(carboxymethyl)lysine (CML), soluble RAGE (sRAGE), and endogenous secretory RAGE (esRAGE) with adiposity, inflammatory markers [interleukin-6 (IL-6), C-reactive protein, tumor necrosis factor-α], adiponectin, lipids, insulin sensitivity, and insulin secretory capacity. Results: Pediatric CML levels were ∼20% below average adult levels. CML was significantly (p < 0.05) positively correlated with age and insulin sensitivity and negatively with adiposity, dyslipidemia and IL-6. sRAGE correlated positively with esRAGE and negatively with adiposity and IL-6. Both sRAGE and esRAGE correlated negatively with insulin secretory capacity. Conclusion: Our findings suggest that unlike adults, CML is negatively associated with adiposity and adiposity-related comorbidity risk in children. As in adults, sRAGE and esRAGE were, to varying degrees, negatively correlated with body fatness and risk factors for adiposity-related comorbidities.

Background The prevalence of obesity in U.S. has been rising at an alarming rate,particularly among Hispanic, African, and Asian minority groups. This trendis due in part to excessive calorie consumption and sedentary lifestyle. Wesought to investigate whether parental origins influence eating behaviors inhealthy urban middle school students. Methods A multiethnic/racial population of students (N = 182) enrolled inthe ROAD (Reduce Obesity and Diabetes) Study, a school-based trial to assessclinical, behavioral, and biochemical risk factors for adiposity and itsco-morbidities completed questionnaires regarding parental origins, lengthof US residency, and food behaviors and preferences. The primary behavioralquestionnaire outcome variables were nutrition knowledge, attitude,intention and behavior, which were then related to anthropometric measuresof waist circumference, BMI z-scores, and percent body fat. Two-way analysisof variance was used to evaluate the joint effects of number of parents bornin the U.S. and ethnicity on food preference and knowledge score. TheTukey-Kramer method was used to compute pairwise comparisons to determinewhere differences lie. Analysis of covariance (ANCOVA) was used to analyzethe joint effects of number of parents born in the US and student ethnicity,along with the interaction term, on each adiposity measure outcome. Pearsoncorrelation coefficients were used to examine the relationships betweenmaternal and paternal length of residency in the US with measures ofadiposity, food preference and food knowledge. Results African Americans had significantly higher BMI, waist circumference and bodyfat percentage compared to other racial and ethnic groups. Neitherethnicity/race nor parental origins had an impact on nutrition behavior.Mothers’ length of US residency positively correlated withstudents’ nutrition knowledge, but not food attitude, intention orbehavior. Conclusions Adiposity measures in children differ according to ethnicity and race. Incontrast, food behaviors in this middle school sample were not influenced byparental origins. Longer maternal US residency benefited offspring in termsof nutrition knowledge only. We suggest that interventions to preventobesity begin in early childhood.

Objective In adults, elevated levels of retinol binding protein 4 (RBP4) have been associated with biochemical markers of adiposity-related co-morbidities including insulin resistance, dyslipidemia, hypertension, and abdominal obesity. This study examined the relationship between RBP4 and risk factors for co-morbidities of adiposity in a population of ethnically diverse children in early- to mid-adolescence in the public school system of New York City. Materials/methods We analyzed anthropometric (body mass index, % body fat, waist circumference), metabolic (lipids, glucose), and inflammatory (TNF-alpha, interleukin-6, C-reactive protein, adiponectin) markers for adiposity-related co-morbidities and serum alanine aminotransferase (ALT) in 106 school children (65 males, 41 females) 11-15 years of age (mean +/- SD = 13.0 +/- 0.1 years) who were enrolled in the Reduce Obesity and Diabetes (ROAD) project. Insulin sensitivity was assessed by quantitative insulin sensitivity check index. Insulin secretory capacity was measured as acute insulin response and glucose disposal index. Results Serum RBP4 was significantly correlated directly with ALT, triglycerides, and triglyceride z-score, and inversely correlated with adiponectin. Correlations with ALT and adiponectin remained significant when corrected for % body fat, age, and gender. There were significant ethnic differences in the relationship of RBP4 to ALT, glucose disposal index and adiponectin. Conclusions In early- to mid-adolescents, circulating concentrations of RBP4 are correlated with multiple risk factors for adiposity-related co-morbidities. The observation that many associations persisted when corrected for % body fat, suggests that RBP4 can be viewed as an independent marker of adiposity-related co-morbidity risk in children.

OBJECTIVES: Protracted bacterial bronchitis is defined as the presence of more than 4 weeks of chronic wet cough that resolves with appropriate antibiotic therapy, in the absence of alternative diagnoses. The diagnosis of protracted bacterial bronchitis is not readily accepted within the pediatric community, however, and data on the incidence of bacterial bronchitis in children are deficient. The objective of this study was to determine the frequency of bacterial bronchitis in children with chronic wet cough and to analyze their bronchoscopic findings. METHODS: We performed a retrospective review of charts of children who presented with chronic wet cough, unresponsive to therapy, before referral to the pediatric pulmonary clinic. RESULTS: A total of 197 charts and bronchoscopy reports were analyzed. Of 109 children who were 0 to 3 years of age, 33 (30.3%) had laryngomalacia and/or tracheomalacia. The bronchoscopy showed purulent bronchitis in 56% (110) cases and nonpurulent bronchitis in 44% (87). The bronchoalveolar lavage bacterial cultures were positive in 46% (91) of the children and showed nontypable Haemophilus influenzae (49%), Streptococcus pneumoniae (20%), Moraxella catarrhalis (17%), Staphylococcus aureus (12%), and Klebsiella pneumoniae in 1 patient. The χ2 analysis demonstrated that positive bacterial cultures occurred more frequently in children with purulent bronchitis (74, 69.8%) than in children with nonpurulent bronchitis (19, 19.8%) (P < .001). CONCLUSIONS: Children who present with chronic wet cough are often found to have evidence of purulent bronchitis on bronchoscopy. This finding is often indicative of a bacterial lower airway infection in these children.

Objectives To evaluate the perceived impact of work-hour limitations on paediatric residency training programmes and to determine the various strategies used to accommodate these restrictions. Methods A three-page pre-tested survey was administered to programme directors at the 2004 Association of Paediatric Programme Directors meeting. The impact of work-hours was evaluated with Likert-type questions and the methods used to meet work-hour requirements were compared between large programmes (≥30 residents) and small programmes. Results Surveys were received from 53 programme directors. The majority responded that work-hour limitations negatively impacted inpatient continuity, time for education, schedule flexibility and attending staff satisfaction. Supervision by attending staff was the only aspect to significantly improve. Perceived resident satisfaction was neutral. To accommodate work-hour limitations, 64% of programmes increased clinical responsibility to existing non-resident staff, 36% hired more non-resident staff and 17% increased the number of residents. Only one programme hired additional non-clinical staff. Large programmes were more likely to use more total methods on the inpatient wards (P

Distinguished members of the Ambulatory Pediatric Association (APA) and guests, it is indeed a distinct and unique honor for me to be standing here before you accepting this most distinguished award. The almost 40 years of Armstrong lectureships have spanned a remarkable group of individuals and topic areas, which together form a history of some of the most important issues facing our children and our society over the decades. In many ways, they reflect the mission and vision of George L. Armstrong, the pediatrician whose name we use for this esteemed lectureship. Armstrong represents for us a "beacon of dedication and determination toward bringing a healthier world for children in our society," to quote my introduction to the volume of collected lectureships I edited for our organization's 30th anniversary celebration. On the founding, in 1769, of the first dispensary for children in Red Lion Square in London, England, Dr Armstrong's

There clearly are a large number of opportunities to use the media to influence legislation and legislative initiatives. There are a number of examples of legislation or laws that now exist as a result of pediatricians using the media effectively. National requirements for child auto restraints, Consumer Product Safety Commission regulations on children's toys, safety caps on medications, bicycle helmet laws, and increasing restrictions on guns can all be traced, in part, to the timely and appropriate use of the media. North Carolina safe gun laws to protect children resulted from pediatricians using some unfortunate and tragic incidents to dramatize the need for gun control. Highlighting the inappropriate care for children in emergency situations in New Jersey contributed to the movement to enact pediatric emergency care guidelines for that state. Finally, the effective use of the media by the AAP has brought a number of serious, child-related issues to the legislative forefront resulting in improved conditions for children. It is not easy, though. To use the media effectively takes persistence, thoughtful attention to developing relationships with the professionals in the media, and careful follow-up. It's important that pediatricians speak out on behalf of children and children's needs. The media, when used properly and knowledgeably, can be a powerful ally and contributor to a better outcome.

Following reports of concern among health-care workers regarding the occupational risk of infection with the human immunodeficiency virus (HIV), a symposium was designed in 1987 to demonstrate to health-care providers at three hospitals in The Bronx, New York, the low risk of occupational HIV infection and techniques for avoiding infection. After the symposium, 103 of the health-care providers who had attended it completed a questionnaire assessing the impact of the symposium on their attitudes; the responses from 100 of these providers were used in this study. Twenty-nine of the responding providers reported that the symposium had increased their concerns regarding their risk of HIV infection; this group was composed of seven of the 15 medical students who responded, 12 of the 36 housestaff, seven of the 28 faculty, and three of the 21 other medical staff. The findings of the present study suggest that a symposium designed to decrease concerns of occupational HIV infection among health-care workers may have the opposite effect on some of those who attend it, especially medical students. Education alone may be inadequate to reassure some providers. The authors recommend small-group sessions addressing the emotional aspects of health-care providers' concerns.

Even though fever, as part of the inflammatory response, is only a sign of an underlying pathologic stress, we seem to have the need to treat it with a drug or a sponge, as if it were the noxious culprit itself. In contrast to hyperthermia, fever rarely poses any threat to a child's well-being; in fact, it has been argued that as an energy-expensive process, it is not likely to have weathered evolution without conferring some survival benefit. Because fever is the most frequent signal of illness in children, serving as the chief complaint for as many as one third of all pediatric office visits, we do well to understand fever as a phenomenon distinct from the illnesses that cause it.

Liquid forms of antiepileptic drugs (AEDs) may be syrups or elixirs (in which the AED is in solution in water or alcohol, respectively) or suspensions. Suspensions consist of finely divided medication dispersed in an inactive carrier. The following are common reasons for the use of liquid forms of AEDs: 1) ease of measurement of doses that do not correspond to available tablet or capsule form; 2) ease of administration to children or adults who are unable to swallow or chew capsule, tablet, or chewable tablet forms of the drug; and 3) for persons who must receive all enteral medications through nasogastric or gastrostomy tubes.

Self-help support groups for medical students represent one strategy for dealing with the emotional stresses of medical training and the diminished human sensitivity of students that often accompanies that experience. Support groups at the Albert Einstein College of Medicine were evaluated by 26 students who completed a nine-part questionnaire. The respondents indicated that they were primarily drawn to these groups because of a desire for social affiliation and an opportunity to express their feelings in a "safe" environment. Members shared in the leadership responsibilities of the group and dealt with external personal problems of the students rather than with the internal group dynamics. The gains derived from participation in these groups included opportunities for nonprofessional contact with faculty members, getting help and support from fellow students, and participation in stimulating discussions about the medical field. Students rated the groups as "meaningful" and expressed a desire for more frequent meetings.

Concerns regarding accidental needle puncture wounds, needle injuries among house officers have increased following reports of human immunodeficiency virus (HIV) transmission via this route. Pediatric house officers training in areas with large numbers of children infected with HIV may face a significant risk of occupational HIV infection via needle injury. The cumulative incidence of needle injury among pediatric house officers in New York who completed at least 1 year of training was ascertained. A questionnaire designed to elicit retrospective information regarding needle injuries was completed by 294 house officers in medical school-affiliated pediatric training programs. A total of 205 (69.7%) had stuck themselves or been stuck with a needle contaminated with a patient's blood, and 48 (17%) reported a needle injury involving a needle contaminated with the blood of a patient with suspected HIV infection. Only 11 of the 48 had received counselling or HIV testing following their possible HIV exposure. These data indicate that needle injury among pediatric house officers in New York is common. Reducing occupational risk is an especially compelling policy issue for pediatric training programs in areas where HIV is endemic.

To assess the value of routine chest radiography during acute first attacks of asthma, we studied 371 consecutive children over one year of age who presented with an initial episode of wheezing. Three hundred fifty children (94.3 per cent) had radiographic findings that were compatible with uncomplicated asthma and were considered negative. Twenty-one (5.7 per cent) had positive findings: atelectasis and pneumonia were noted in seven, segmental atelectasis in six, pneumonia in five, multiple areas of subsegmental atelectasis in two, and pneumomediastinum in one. The patients with positive films were more likely to have a respiratory rate above 60 or a pulse rate above 160 (P less than 0.001), localized rales or localized decreased breath sounds before treatment (P less than 0.01), and localized rales (P less than 0.005) and localized wheezing (P less than 0.02) after treatment; also, these patients were admitted to the hospital more often (P less than 0.001). Ninety-five per cent (20 of 21) of the children with positive films could be identified before treatment on the basis of a combination of tachypnea, tachycardia, fever, and localized rales or localized decreased breath sounds. Most first-time wheezers will not have positive radiographs; careful clinical evaluation should reveal which patients will have abnormal radiographs and will therefore benefit from the procedure.

The Welch Allyn AudioScope is a new screening instrument that allows both audiometric testing at 500, 1000, 2000, and 4000 Hz at 25 dB hearing level and otoscopic examination. Sixty-eight patients between 3 and 9 years of age with normal hearing or a variety of hearing losses comprised the study population. Immediately after receiving an audiologic evaluation the subjects were screened with a traditional screening audiometer and two examinations with the AudioScope, performed in a clinic examining room by pediatricians and nurse practitioners unaware of the children's hearing status. The AudioScope was as accurate as traditional hearing screening in identifying children with normal hearing and those with hearing loss. Log-linear modeling demonstrated that the results of AudioScope testing were similar to those of traditional hearing screening. However, the false positive rate was higher at 500 Hz for the first AudioScope examination, suggesting the need for two AudioScope tests. The AudioScope was quick and easy to use, nonthreatening to the subjects, less expensive than a pure-tone screening audiometer, and does not require a sound-treated room.

Questionnaires were used to survey 1,435 parents and 446 physicians in order to determine and compare attitudes and beliefs about enuresis. Although both groups thought that bed-wetting is a maturational problem, the parent group thought emotional causes were important and were less likely to accept small bladder size as an etiology. Parents thought that children should be dry at a much younger age than did the physicians (2.75 vs 5.13 years, respectively). Only 63% of parents thought that medical intervention is a good way to deal with a child's bed-wetting, yet 87% of the physicians suggested medical evaluation. A comparison of the various methods used to stop bed-wetting indicated that parents use waking the child, reassurance and talking with the child, restricting fluids, and punishment significantly more often than physicians. Although many physicians prescribe medication, only 6.6% of the parents thought that medicines are a "very good way" to treat enuresis. When developing a treatment plan for a child with enuresis, the physician should recognize the wide differences between parental and physician attitudes toward this common problem of childhood.

Since the mid-1970s, the federal government has supported residencies in general pediatrics, family practice, and general internal medicine, under Title VII of the Public Health Services Act. The need for continued targeted federal support for primary care has been questioned by those who predict that a physician surplus will produce the needed number of primary care providers without special programs. At a time of federal deficits and budget cutting, funding for all graduate medical education is under review, but primary care programs are especially vulnerable since these programs do not automatically command a large academic or political constituency. Before deciding to abandon targeted programs, it seemed reasonable to examine whether they had achieved the stated government goals. For example, the original Public Health Service legislation encouraged the production of generalists, as opposed to specialists. Representatives of family practice and general internal medicine have reported that graduates in these specialties have

Leukotrienes (LT) have been proposed to be important mediators in the etiology of the acute asthma attack (AAA). We therefore studied blood LT levels in 18 children having AAA. Heparinized blood samples were obtained before and after treatment with epinephrine injections and/or metaproterenol inhalations in the emergency room. The samples were acidified and subjected to Sep-pak chromatography. Reverse phase high performance liquid chromatography (RP-HPLC), ultraviolet (UV) spectroscopy and bioassay on guinea pig ileum were used to identify the LT based on comparison to data produced by standard synthetic LT samples. Radioimmunoassay (RIA) was used to further confirm the presence of LT LT C, D and E were detected in the plasma of children having AAA. Only LT C levels were significantly elevated over control values. The mean blood LT C level of control patients was 1.6 ± 1.2 nanograms per milliliter (ng/ml, mean t SEM) while that of the asthma patients was 73.8 ± 18.2 ng/ml prior to treatment. After emergency room treatment the asthma patients had a mean blood LT C level of 22.5 ± 11.7 ng/ml. Lowered levels of LT C accompanied improved clinical condition of the patients. This finding indicates that the AAA in children is associated with elevated blood levels of LT C.

One hundred and seventy-five infants less than 8 weeks of age, presenting to the pediatric emergency room of the Bronx Municipal Hospital Center with rectal temperature greater than or equal to 38 degrees C (100.4 degrees F), were studied. House officers recorded their impressions of the infants on a number of variables prior to performing a lumbar puncture and obtaining laboratory data. All infants were admitted for parenteral antibiotic therapy pending culture results. Culture-positive bacterial infections occurred in 6.3% (n = 11); the incidence of bacteremia was 3.4% (n = 6). Of special concern were the 134 infants who had no visible source for their fever during the first examination. A major goal was to determine whether there were any early predictors of bacteremia in this group. The individual variables of white blood cell count greater than or equal to 15,000/mm3, band count greater than or equal to 500/mm3, temperature, impression of irritability, tone, cry, and activity level were not related to the presence of bacteremia. An erythrocyte sedimentation rate greater than or equal to 30 and the examiner's impression of sepsis were significantly associated with bacteremia but did not correctly identify all cases. However, the combination of impression of sepsis, white blood count greater than or equal to 15,000/mm3, and erythrocyte sedimentation rate greater than or equal to 30 identified all infants with bacteremia and excluded 82% of the infants who were eventually shown not to have bacteremia.

• Of 1,379 children 4 years of age and older who were patients in nine medical centers across the country, 346 (25.1%) were found to be enuretic. Their parents considered heavy sleeping and emotional problems as the main causes of enuresis in children; physical causes rarely were believed to be important. "Waking up the child" from sleep to urinate and "talking about the problem" were the main methods that parents used to treat enuresis. Very few used medication. Parents with a grade school level of education punish bed-wetting children at twice the rate of high school- and college-educated parents. Physicians need to be more aware that enuresis is an important problem for parents and that there are many widely held beliefs about cause and management. ( Am J Dis Child 1981;135:809-811)