Children's Mercy Hospital Research Articles

Urological Disorders in Chronic Kidney Disease in Children Cohort: Clinical Characteristics and Estimation of Glomerular Filtration Rate

Urological disorders are the most common cause of pediatric chronic kidney disease. We determined the characteristics of children with urological disorders and assessed the agreement between the newly developed bedside glomerular filtration rate estimating formula with measured glomerular filtration rate in 586 patients in the Chronic Kidney Disease in Children study. The Chronic Kidney Disease in Children study is a prospective, observational cohort of children recruited from 48 sites in the United States and Canada. Eligibility requirements include age 1 to 16 years and estimated glomerular filtration rate by original Schwartz formula 30 to 90 ml/min/1.73 m(2). Baseline demographics, clinical variables and glomerular filtration rate were assessed. Bland-Altman analysis was conducted to assess agreement between estimated and measured glomerular filtration rates. Of the 586 participants with at least 1 glomerular filtration rate measurement 348 (59%) had an underlying urological diagnosis (obstructive uropathy in 118, aplastic/hypoplastic/dysplastic kidneys in 104, reflux in 87 and other condition in 39). Among these patients median age was 9 years, duration of chronic kidney disease was 7 years and age at first visit with a urologist was less than 1 year. Of the patients 67% were male, 67% were white and 21% had a low birth weight. Median height was in the 24th percentile. Median glomerular filtration rate as measured by iohexol plasma disappearance was 44.8 ml/min/1.73 m(2). Median glomerular filtration rate as estimated by the Chronic Kidney Disease in Children bedside equation was 44.3 ml/min/1.73 m(2) (bias = -0.5, 95% CI -1.7 to 0.7, p = 0.44). Underlying urological causes of chronic kidney disease were present in 59% of study participants. These children were diagnosed early in life, and many had low birth weight and growth delay. There is good agreement between the newly developed Chronic Kidney Disease in Children estimating equations and measured glomerular filtration rate in this population.

A “Narcotics Contract” for a Patient With Sickle Cell Disease and Chronic Pain

For many physicians, the treatment of chronic pain is one of the most difficult clinical and ethical challenges that they encounter. Patients with chronic pain can be demanding, frustrating, and mystifying. In pediatrics, sickle cell disease (SCD) is a common cause of chronic pain. In this issue's “Ethics Rounds,” we present the case of a patient with SCD and ask 2 experts on pain management to discuss the clinical and ethical issues. Carlton Dampier is a professor of pediatrics and assistant dean for clinical research at the Emory University School of Medicine; Carlton Haywood Jr is an assistant professor of medicine and core faculty in bioethics at the Johns Hopkins University. C.K. is an 18-year-old woman with SCD who has had dozens of hospital admissions and numerous visits to a clinic and the emergency department (ED) for pain crises. Over the previous year she often presented to the ED for treatment of her pain without having first called her hematologists. They have recommended — and stressed — that it would be better to call them first, because they know her and her disease and might be able to manage her pain at home and prevent the need for an ED visit. C.K. has generally listened attentively and promised to call the hematologists before going to the ED, but she then shows up at the ED unannounced. In the ED, and on the wards when admitted, C.K.'s subjective evaluations of her degree of pain were often at odds with objective parameters such as vital signs and demeanor. Many times she experienced virtually no significant improvement with intravenous ketorolac or hydromorphone dispensed through a patient-controlled analgesia pump. Even an exchange transfusion did not diminish her reported pain despite a postexchange hemoglobin S percentage of zero. Her doctors recommended psychotherapy. She initially refused … Address correspondence to John D. Lantos, MD, Children's Mercy Hospital, 2401 Gillham Rd, Kansas City, MO 64108. E-mail: jlantos{at}cmh.edu

A next generation sequencing test

A next generation sequencing test

Case Records of the Children's Mercy Hospital

Straddle injuries are common in children. At the end of this case presentation, you should be able to describe the approach to the evaluation and treatment of a straddle injury, list indications for gynecologic consultation and/or sedation, plan disposition, and discuss pitfalls to avoid in evaluating patients with straddle injuries.

The Impact of Parenteral Narcotic Choice in the Development of Acute Chest Syndrome in Sickle Cell Disease

Acute chest syndrome (ACS) represents a serious morbidity and often fatal complication in patients with sickle cell disease. Painful episodes which require hospitalization are most often treated with opioids, which may then influence the development of ACS. Nalbuphine is a parenteral opioid which effectively treats pain and may cause less ACS. This retrospective chart review documented 988 admissions for painful episodes at 2 institutions and recorded the incidence of ACS and opioid used. At the Children's Hospital in St Louis, Missouri, the incidence of ACS in patients treated with morphine alone was 10.8% versus at the Children's Mercy Hospital in Kansas City, Missouri, the incidence was 2.1% for patients treated solely with nalbuphine. When nalbuphine is used alone as the single parenteral opioid agent to treat painful episodes in patients with sickle cell disease, the incidence of ACS is less than when compared with other opioids used to treat pain.

Molecular epidemiology and clinical presentation of human adenovirus infections in Kansas City children

Background A significant increase in adenovirus detection among patients at the Children's Mercy Hospital, Kansas City was observed between June 2007 and January 2008. Objective To molecularly characterize the human adenoviruses and describe their association with clinical illness in children. Study design One hundred adenovirus-positive specimens from 79 children were typed by hexon gene sequence typing method. Restriction enzyme analysis (REA) was performed on isolates of HAdV-3, -7 and -14 to identify genomic variants. Medical records were reviewed to understand the clinical illnesses associated with adenovirus serotypes and genome types. Results The most prevalent HAdV serotypes were HAdV-3 (37%), HAdV-7 (25%), HAdV-1 (16%), HAdV-2 (8%). HAdV infection was common in children ≤3 years of age (71%) versus children >3 years (29%). Majority of the HAdV-infected children were hospitalized (78%); 22/79 (28%) stayed >3 days and 8/79 (10%) required intensive care unit stay. Hospitalization rates for HAdV-3 (36%) and HAdV-7 (25%) were comparable. REA data indicated that HAdV-3a2 was the predominant HAdV-3 genome type. Two novel genomic variants of HAdV-3 exhibiting unique BglII or BstEII profiles were identified in isolates from patients with bronchiolitis. All HAdV-7 and -14 isolates were identified as corresponding to genome types 7d2 and 14p1, respectively. Conclusions In Kansas City, we noticed an increase in the incidence of HAdV-7 (25%; n = 24/98) infections compared to the previous two years (6%; n = 6/107). Two new genomic variants of HAdV-3 appear to have emerged in our area and seem to be associated with lower respiratory tract infections in children.

Venereal Warts in Children

1. Kelly A. Sinclair, MD* 2. Charles R. Woods, MD, MS† 3. Sara H. Sinal, MD§ 1. *Emergency Medical Services, The Children's Mercy Hospital and Clinics, Kansas City, MO. 2. †Department of Pediatrics, University of Louisville School of Medicine, Louisville, KY. 3. §Department of Pediatrics, Wake Forest University Health Sciences, Winston-Salem, NC. After completing this article, readers should be able to: 1. Describe the natural history and epidemiology of anogenital human papillomavirus infection. 2. Discuss diagnosis and treatment options for children who have anogenital warts. 3. Recognize when anogenital warts are suggestive of child sexual abuse and what steps are needed to manage this clinical problem. More than 24 million cases of human papillomavirus (HPV) infection occur in adults in the United States, with an estimated 1 million new cases developing each year. The number of outpatient visits for adults who have venereal warts (condyloma acuminata) increased fivefold from 1966 to 1981. (1) HPV infections in children may present as common skin warts, anogenital warts (AGW), oral and laryngeal papillomas, and subclinical infections. The increased incidence of AGW in children has paralleled that of adults. AGW in children present a unique diagnostic challenge: Is the HPV infection a result of child sexual abuse (CSA), which requires reporting to Child Protective Services (CPS), or acquired through an otherwise innocuous mechanism? Practitioners must balance “missing” a case of CSA if they do not report to CPS against reporting to CPS and having parents or other caregivers potentially suffer false accusation and its potential ramifications, which may include losing custody of children. In the past, simply identifying AGW in a young child was considered indicative of CSA by some experts. However, there is no defined national standard beyond the limited guidance provided in the 2005 American Academy of Pediatrics (AAP) Policy Statement, which states that AGW are suspicious for CSA if not perinatally acquired and the …

Human Parechovirus 3 Causing Sepsis-like Illness in Children From Midwestern United States

: Human parechovirus (HPeV) infections of the central nervous system (CNS) in children can be associated with severe outcomes such as neonatal sepsis-like illness, meningitis, or paralysis. We sought to determine the prevalence of HPeV CNS infections and clinical presentation in children from the United States. : Frozen nucleic acid extracts from enterovirus-negative cerebrospinal fluid (CSF) obtained at the Children's Mercy Hospitals and Clinics, in Kansas City from 2006 (n = 242), 2007 (n = 324), and 2008 (n = 218) were tested by 2-step HPeV real-time reverse transcription polymerase chain reaction. HPeV genotype was determined by sequencing the VP3/VP1 junction. Demographic and clinical data were abstracted from medical records. : Overall HPeV was detected in 58/780 (7%) of tested CSF samples; 4/218 (2%) in 2006, 54/320 (17%) in 2007, and 0/242 (0%) in 2008. HPeV (17%) and enterovirus (20%) detection were comparable in 2007. HPeV-3 genotype was detected in 52/53 specimens successfully sequenced. Detection was seasonal (June-October). HPeV-3-CNS-infection occurred at a mean age of 6.6 ± 4.4 weeks and predominantly in males (71%). The most common clinical presentation was sepsis-like syndrome (66%). The most common symptoms were irritability (98%), fever (95%), and nonspecific rash (58.6%), while neurologic manifestations were rare (5%). : To our knowledge, this is the first multiyear prevalence report of HPeV CNS infection in the United States. HPeV CNS infection was detected mostly in male infants with sepsis-like illness during the late summer/autumn season. Routine seasonal CSF testing in infants for HPeV plus enterovirus may improve etiologic detection and clinical management of infantile sepsis-like presentations.

Harry Truman and Health Care Reform: The Debate Started Here

The signing of the Patient Protection and Affordable Care Act in March 2010 has not quelled the bitter debate over the issue of health care reform. National health insurance (NHI) plans have been considered by many presidential administrations since the beginning of the 20th century. Harry Truman (Fig 1) was the first US president to propose a system of NHI, however, when he addressed Congress on November 19, 1945.1 He had already included “the right to adequate medical care and the opportunity to achieve and enjoy good health” in his proposed Economic Bill of Rights. For Truman, the words did not go far enough. As a Jackson County, Missouri, judge, he had seen firsthand the disastrous effects that illness could have on a working family through his responsibility for the county poorhouse.2 He later learned that one-third of Selective Service registrants were rejected during World War II. In addition, many soldiers were discharged for health problems unrelated to combat, and still more were treated for conditions that predated their military induction. In his speech, Truman enumerated basic problems with health care delivery, including high costs and loss of earnings during illness. In response, he proposed compulsory NHI for all Americans and expanded social insurance systems to include replacement of lost earnings. FIGURE 1 President Harry S. Truman with March of Dimes children, 1950. Copyright unknown, courtesy of the Truman Library. NHI was not a new concept. Otto von Bismark initiated a compulsory health insurance program in Germany in 1883; its success led to the expansion of the concept of social insurance across Europe and the … Address correspondence to Robert D. Schremmer, MD, Division of Emergency Medical Services, Children's Mercy Hospitals and Clinics, 2401 Gillham Rd, Kansas City, MO 64108. E-mail: rschremmer{at}cmh.edu

Outcomes of Implementing Rapid Triage in the Pediatric Emergency Department

Efficiency and effectiveness are often used as quality indicators in emergency departments. With an aim to improve patient throughput and departmental efficiency while decreasing left-without-being-seen (LWBS) rates, this two-group, pre-intervention, post-intervention study in a pediatric emergency department evaluated the outcomes of implementing rapid triage on arrival-to-triage time, fast track utilization, and LWBS. We implemented rapid triage assessment integrating the Emergency Severity Index and fast track guidelines in our pediatric emergency department. Arrival-to-triage times were tracked for 1 month before and after the intervention (N = 13,910 patient visits) by recording the time the patient arrived in the department and time triage assessment was complete. Fast track utilization and LWBS rates were measured for all patients sequentially included in pre-intervention (n = 60,373) and post-intervention (n = 67,939) groups for 10 months. After the intervention, patients experienced a significant decrease in arrival-to-triage times compared with the pre-intervention group (P < .001), with most patients (88.3%) being triaged in less than 10 minutes after the intervention. Following implementation of fast track guidelines, patients were 14% more likely to be triaged to fast track compared with pre-intervention patients (odds ratio [OR] = 1.14, 95% confidence interval [CI] = 1.11-1.67). Additionally, patients with the lowest acuity were nearly 50% more likely to be triaged to fast track compared with pre-intervention patients (OR = 1.48, 95% CI = 1.35-1.63). Although LWBS rates were insignificant, overall acuity level of this group was lower in the post-intervention group. Although LWBS rates did not decrease with the intervention, implementation of a rapid triage system and fast track guidelines reduced arrival-to-triage times and decreased acuity in the LWBS population. Implementing rapid triage and fast track guidelines can affect nurse-sensitive patient outcomes related to safety and care delivery in a pediatric emergency department.

Bone Marrow Donation Between Siblings Living in Different Families

Minor siblings are often considered as potential bone marrow donors when a child needs a bone marrow transplant. The practice of using minors as bone marrow donors is ethically controversial, because there is some risk to the donor—and some pain and suffering—but no medical benefit. Nevertheless, most courts and most ethics committees have sanctioned bone marrow donation procedures as long as the donor and the recipient are in the same family and have an emotional tie. Presented here is a case that pushes the limits of those criteria; we asked Drs Doug Diekema, Steve Joffe, and Andrea Vandeven to comment on the ethical issues raised by this unusual case. Dr Diekema is immediate past-chair of the American Academy of Pediatrics Committee on Bioethics; Dr Joffe is a pediatric oncologist at Boston Children's Hospital; and Dr Vandeven is a member of the child-protective-services (CPS) team at Children's Mercy Hospital in Kansas City, Missouri. K. B. was a 7-week-old girl who was brought to the emergency department for poor weight gain. She was 3 oz over her birth weight. Her parents reported that she had been taking 2 oz of formula every 2 to 3 hours. However, doctors in the emergency department noted that the parents did not know how to feed her and fell asleep while she was crying. CPS was called. They were familiar with the family, because a 17-month-old sister had been previously removed from the home for neglect and placed with a foster family. After an extensive medical workup, K. B. was diagnosed with infantile osteopetrosis. The only treatment for this disease is a bone marrow transplant. Children who do not receive a transplant usually die in the first decade of life. The foster family that had taken the 17-month-old sibling were planning to adopt her but were … Address correspondence to John D. Lantos, MD, Department of Pediatrics, Children's Mercy Hospital, 2401 Gillham Rd, Kansas City, MO 64108. E-mail: jlantos{at}cmh.edu

Ethics Rounds—Symbolic Resuscitation, Medical Futility, and Parental Rights

What should doctors do when they are caring for a dying child with a complex, chronic condition and whose parents will not agree to palliative care? What if those parents are cognitively delayed and have lost legal custody of the child because of their inability to care for her? This month's Ethics Rounds concerns a child with septo-optic dysplasia and respiratory failure. She is cared for by her grandmother and is legally a ward of the state. The doctors think that a do-not-resuscitate order is appropriate. Her grandmother agrees and is even ready to withdraw ventilator support. Her parents disagree. We asked 2 experts in bioethics consultation and palliative care to comment on this case. Joel Frader is Chief of General Academic Pediatrics and Medical Co-Director of Pediatric Palliative Care at Children's Memorial Hospital in Chicago, Illinois. Eric Kodish is Chair of the Department of Bioethics at the Cleveland Clinic in Cleveland, Ohio. D. K. is a 2-year-old girl with septo-optic dysplasia, microcephaly, seizure disorder, and severe developmental delay who is intubated for respiratory syncytial virus with respiratory failure. Her past medical history is significant for microcephaly and severe developmental delay since birth. Her baseline functioning is minimal — she has no purposeful movement and no speech or comprehension of language. She is unable to swallow and is given nutrition through a gastrostomy tube. Both of her parents are developmentally delayed and were unable to care for her at home. The state placed her with the maternal grandmother. Although the mother and father no longer have custody, they have been in the PICU and at the bedside daily since the patient was admitted to the hospital. The patient was admitted in respiratory failure and intubated. On the second hospital day, she suffered an acute respiratory decompensation on the ventilator and … Address correspondence to John D. Lantos, MD, Children's Mercy Bioethics Center, Children's Mercy Hospital, 2401 Gillham Road, Kansas City, MO 64108. E-mail: jlantos{at}cmh.edu

University of Missouri—Kansas City School of Medicine

University of Missouri—Kansas City School of Medicine

A Premature Infant With Necrotizing Enterocolitis Whose Parents Are Jehovah's Witnesses

With this article, we introduce a new feature in Pediatrics called “Ethics Rounds.” The goal of this new feature is to present clinical cases that raise ethical issues. We present each case to pediatricians and bioethicists, who comment on the case on the basis of the information that they have at the time. We then give these same commentators the conclusion of the case and ask for further reflections. The case is printed in italic font, and comments are in normal, Roman font. To protect patient privacy, we change certain facts of each case. Thus, although the reports are based on real cases, the names, ages, location, and gender of the patient may be changed if they are not relevant to the central issues of the case. We invite readers to submit cases to the editor of Ethics Rounds: John Lantos, MD (jlantos@cmh.edu). Our first case involves an extremely premature infant who developed necrotizing enterocolitis (NEC). We presented the case, as it evolved, to 2 experienced pediatrician-bioethicists, Dr William Meadow and Dr Chris Feudtner. We then asked another pediatrician-bioethicist, Armand H. Matheny Antommaria, who has training in religious ethics to comment on the case and the discussion. Infant Smith was born at 25 weeks' gestation by emergency cesarean delivery after placental abruption. His birth weight was 475 g. He was stable for the first 4 days. A head ultrasound on day 2 showed a grade II intraventricular hemorrhage on the right. He had oxygen saturation levels of 94% on low ventilator settings. On day 5, Infant Smith experienced a decrease in oxygen saturation and abdominal distension. An abdominal radiograph showed free air in the abdomen. A surgical consult was obtained, and an exploratory laparotomy was scheduled. As part of the consent for surgery, the parents were asked to consent … Address correspondence to John Lantos, MD, Children's Mercy Bioethics Center, Children's Mercy Hospital, 2401 Gillham Rd, Kansas City, MO 64108. E-mail: jlantos{at}cmh.edu

The effect of volume conductor modeling on the estimation of cardiac vectors in fetal magnetocardiography

Event Abstract Back to Event The effect of volume conductor modeling on the estimation of cardiac vectors in fetal magnetocardiography Mihai Popescu1*, Rong Tao2, Anda-Elena Popescu2 and William Drake3 1 Kansas University Medical Center , Physiology Department, United States 2 University of Kansas Medical Center, Hoglund Brain Imaging Center, United States 3 Children's Mercy Hospitals and Clinics, United States In order to attain clinical relevance, fetal magnetocardiography (fMCG) must provide unequivocal and consistent measures of the fetal cardiac activity by means of adequate volume conductor and source modeling. The objectives of this study were: 1) to develop a standardized analysis of fMCG signals for cardiac vector estimation using 3D reconstructed ultrasound images of the fetal-maternal anatomy, and 2) to determine the sensitivity of the cardiac source estimators to the details of the volume conductor model. 3D volumetric images of the fetus and maternal abdominal tissues were acquired immediately before the fMCG experiments using the Stradwin 3D Ultrasound Acquisition and Visualization software (Cambridge University, UK), with a GE Logiq-P5 ultrasound system for B-scan acquisition and a trakSTAR (Ascension Technology Corp., USA) positioning device attached to the ultrasound probe. Following co-registration and re-slicing of the B-scans, the segmentation of the fetal body, amniotic fluid and maternal abdominal compartments was performed using region growing algorithms and morphological image transformations. A macroscopic source model of fetal ventricular depolarization was positioned at the location of the fetal heart identified on the ultrasound images. The magnetic field produced by the elementary currents of the cardiac source model was computed for the sensor setup of a CTF fetal biomagnetometer (with 83 axial gradiometers) using the discrete formulation of the boundary element method (linear-collocation approach) for piecewise homogeneous volume conductor models. We evaluated the cardiac vector reconstruction (using a MUSIC algorithm and multi-dipolar source modeling) for realistic volume conductors versus simplified spherically symmetric models. Using this strategy, the study provides a more realistic set of error bounds, which can be also of particular use in settings where the 3D maternal-fetal anatomy is not available. Conference: Biomag 2010 - 17th International Conference on Biomagnetism , Dubrovnik, Croatia, 28 Mar - 1 Apr, 2010. Presentation Type: Poster Presentation Topic: MCG: Instrumentation, Modeling, Basic and Clinical Studies Citation: Popescu M, Tao R, Popescu A and Drake W (2010). The effect of volume conductor modeling on the estimation of cardiac vectors in fetal magnetocardiography. Front. Neurosci. Conference Abstract: Biomag 2010 - 17th International Conference on Biomagnetism . doi: 10.3389/conf.fnins.2010.06.00321 Copyright: The abstracts in this collection have not been subject to any Frontiers peer review or checks, and are not endorsed by Frontiers. They are made available through the Frontiers publishing platform as a service to conference organizers and presenters. The copyright in the individual abstracts is owned by the author of each abstract or his/her employer unless otherwise stated. Each abstract, as well as the collection of abstracts, are published under a Creative Commons CC-BY 4.0 (attribution) licence (https://creativecommons.org/licenses/by/4.0/) and may thus be reproduced, translated, adapted and be the subject of derivative works provided the authors and Frontiers are attributed. For Frontiers’ terms and conditions please see https://www.frontiersin.org/legal/terms-and-conditions. Received: 06 Apr 2010; Published Online: 06 Apr 2010. * Correspondence: Mihai Popescu, Kansas University Medical Center, Physiology Department, Kansas, United States, mpopescu@kumc.edu Login Required This action requires you to be registered with Frontiers and logged in. To register or login click here. Abstract Info Abstract The Authors in Frontiers Mihai Popescu Rong Tao Anda-Elena Popescu William Drake Google Mihai Popescu Rong Tao Anda-Elena Popescu William Drake Google Scholar Mihai Popescu Rong Tao Anda-Elena Popescu William Drake PubMed Mihai Popescu Rong Tao Anda-Elena Popescu William Drake Related Article in Frontiers Google Scholar PubMed Abstract Close Back to top Javascript is disabled. Please enable Javascript in your browser settings in order to see all the content on this page.

The Biofeedback Program at Children's Mercy Hospitals and Clinics

Abstract The following article provides a description of the history and development of the biofeedback-assisted relaxation training (BART) program at Children's Mercy Hospitals and Clinics. Biofeedback is an integral component of the multidisciplinary Abdominal Pain and Integrative Pain Management programs. A description of currently employed biofeedback-assisted relaxation training protocols, including alternative training tools (e.g., novel biofeedback games) intended to improve practice compliance is provided. Finally, biofeedback implementation strategies and barriers are considered also.

Long-Term Followup of Dextranomer/Hyaluronic Acid Injection for Vesicoureteral Reflux: Late Failure Warrants Continued Followup

Dextranomer/hyaluronic acid injection of ureteral orifices is a popular option in the treatment of vesicoureteral reflux, with success rates ranging from 69% to 89%. We found only 1 study that followed patients beyond the initial postoperative voiding cystourethrogram, which describes a 96% success rate at 2 to 5 years but defines success as "nondilating" reflux. We examined our dextranomer/hyaluronic acid series to evaluate the long-term (1-year) outcome in children who had resolution of reflux on initial postoperative voiding cystourethrography. We retrospectively reviewed our dextranomer/hyaluronic acid experience from February of 2002 to December of 2005. We determined initial success on early (6 to 12-week) postoperative voiding cystourethrogram. We then evaluated long-term success by obtaining a voiding cystourethrogram at 1 year postoperatively in patients who were initially cured of reflux. In addition, success rates between the first and second halves of our experience were evaluated to account for surgeon experience and modification of technique. Our total success rate at initial voiding cystourethrogram was 73% (246 of 337 total ureters). The success rate in the first half of our experience was 65.9% (112 of 170 ureters) and in the second half was 80.2% (134 of 167). A total of 150 ureteral units with initial successful dextranomer/hyaluronic acid treatment were evaluated at 1 year by voiding cystourethrogram. Of these ureters 111 had continued resolution of vesicoureteral reflux, for a long-term success rate of 74%. Including initial postoperative failures, the complete 1-year total success rate was 46.1% (111 of 241 ureters). Although the reflux resolution rates at initial postoperative voiding cystourethrogram approach those of open surgery, there is a significant failure rate at 1 year, which warrants long-term followup.

Cortisol levels in Prader-Willi syndrome support changes in routine care.

American Journal of Medical Genetics Part AVolume 149A, Issue 2 p. 138-139 Invited Comment Cortisol levels in Prader–Willi syndrome support changes in routine care† Merlin G. Butler, Corresponding Author Merlin G. Butler mbutler4@kumc.edu Departments of Psychiatry & Behavioral Sciences and Pediatrics, Kansas University Medical Center, Kansas City, KansasDepartments of Psychiatry & Behavioral Sciences and Pediatrics, Kansas University Medical Center, 3901 Rainbow Boulevard, MS 4015, Kansas City, KS 66160.Search for more papers by this authorUttam Garg, Uttam Garg Department of Pathology, Children's Mercy Hospital, Kansas City, MissouriSearch for more papers by this author Merlin G. Butler, Corresponding Author Merlin G. Butler mbutler4@kumc.edu Departments of Psychiatry & Behavioral Sciences and Pediatrics, Kansas University Medical Center, Kansas City, KansasDepartments of Psychiatry & Behavioral Sciences and Pediatrics, Kansas University Medical Center, 3901 Rainbow Boulevard, MS 4015, Kansas City, KS 66160.Search for more papers by this authorUttam Garg, Uttam Garg Department of Pathology, Children's Mercy Hospital, Kansas City, MissouriSearch for more papers by this author First published: 09 January 2009 https://doi.org/10.1002/ajmg.a.32633Citations: 6 † How to cite this article: Butler MG, Garg U. 2009. Cortisol levels in Prader–Willi syndrome support changes in routine care. Am J Med Genet Part A 149A:138–139. Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat No abstract is available for this article.Citing Literature Volume149A, Issue2February 2009Pages 138-139 RelatedInformation

21st-Century Use for Surfactant?

The modern era of surfactant-replacement therapy (SRT) is almost 30 years old. Capitalizing on the then-new understanding of surfactant composition and function,1 Fujiwara et al2 opened a new decade and a new era in neonatal medicine with their January 12, 1980, report in the Lancet . Their 10-patient phase II open-label single-center study demonstrated physiologic efficacy of exogenous bovine-derived surfactant in infants with respiratory distress syndrome (RDS). On the heels of this report, multiple studies followed. These studies included single-dose safety trials, efficacy trials, dose-ranging trials, and optimal timing trials, all aimed at preventing or treating RDS. Later trials sought to identify term and preterm infants with disorders other than RDS who might benefit from SRT. These later efforts met with more limited success.3–5 More recently, lucinactant, a synthetic surfactant containing a 21 amino acid peptide, sinapultide, has been tested against other surfactants in the management of RDS.6 Against this bright background of remarkable improvement in mortality rates for very low birth weight infants, the shadow of bronchopulmonary dysplasia (BPD) has lengthened. … Address correspondence to William E. Truog, MD, Children's Mercy Hospitals and Clinics, Section of Neonatology, Department of Pediatrics, 2401 Gillham Road, Kansas City, MO 64108. E-mail: wtruog{at}cmh.edu

Cephalosporins: A Review

1. Christopher J. Harrison, MD* 2. Denise Bratcher, DO* 1. *Children's Mercy Hospitals and Clinics, Pediatric Infectious Diseases, University of Missouri at Kansas City, Kansas City, Mo After completing this article, readers should be able to: 1. Describe the mechanism of action of cephalosporins. 2. Delineate the two most common mechanisms of resistance to penicillins. 3. Discuss the most common adverse effects of common cephalosporins. 4. List which cephalosporins have activity against Pseudomonas. Cephalosporins are beta-lactam antimicrobials that share mechanisms of action and a similar structure with penicillins (Figure⇓). Penicillins and cephalosporins have the same four-member “core” beta-lactam ring, but cephalosporins have an additional atom in the side ring. Modified side chains on either ring alter antimicrobial activity, resistance to beta-lactamases, or pharmacokinetics. Penicillin-susceptible pathogens usually are cephalosporin-susceptible. Exceptions are Listeria and Pasteurella sp. Cephalosporins have activity against common gram-negative organisms such as Escherichia coli , nontypeable Haemophilus influenzae (ntHi), and methicillin-susceptible Staphylococcus aureus (MSSA), but all methicillin-resistant S aureus (MRSA) and enterococci are cephalosporin-resistant. Because of minimal use or current unavailability, we will not discuss cephalothin, moxalactam, cefamandole, cefonicid, ceforanide, ceftizoxime, cefoperazone, cefpirome, cefmetazole, or cefotetan. Figure. Cephalosporin versus penicillin ring structures. The solid arrows indicate the core four-member beta-lactam ring within both penicillins and cephalosporins. Open arrows indicate the five- and six-member side rings for penicillins and cephalosporins, respectively. R indicates additional side chain sites where substitutions of various chemical groups produce different antimicrobial spectra, pharmacokinetics, or stability to beta-lactamases. To help understand the mechanism of action of cephalosporins, rigid bacterial cell walls can be considered as a series of repeating interlocking units reminiscent of floor tiles. During replication, a bacterium removes “tiles” circumferentially to allow cell division via a pinching-like action, while quickly placing new “tiles” at the ends of what have become two bacteria. This process requires enzymes to interlock replacement tiles. Such enzymes are the targets of beta-lactam antibiotics and are called penicillin-binding proteins (PBPs). Antibiotic action requires binding to PBPs, preventing them from closing the …