Burden of rotavirus hospitalisations in young children in three paediatric hospitals in the United States determined by active surveillance compared to standard indirect methods.

AIM: The number of rotavirus hospitalisations is usually estimated from assigned diagnosis codes for gastroenteritis despite lack of validation for these indirect methods. Reliable estimates before and after introduction of vaccines are needed to quantify the absolute impact of new immunisation programs. METHODS: This 2-year study conducted at three hospitals prior to the licensure of the rotavirus vaccines in the USA compared two indirect methods for estimating hospitalisations for rotavirus gastroenteritis with estimates derived from prospective recruitment of children presenting with diarrhoea, vomiting or fever. For active surveillance, rotavirus gastroenteritis was confirmed by demonstration of stool antigen. The indirect residual and proportional methods assumed rotavirus to have caused a proportion of hospitalisations coded as acute gastroenteritis identified from computerised records. RESULTS: There were 447 rotavirus hospitalisations among inpatients 31 days through 4 years of age admitted with vomiting and/or diarrhoea, compared with 306 and 228 hospitalisations identified by the two indirect methods. Only 52% of children hospitalised with gastroenteritis received a qualifying diagnosis code at discharge. Relative to active surveillance, the sensitivity and specificity (95% confidence interval (CI)) in identifying rotavirus-attributable hospitalisations was 45% (95% CI: 43-48%) and 89% (88-90%) for the residual method and 34% (30-39%) and 92% (90-94%) for the proportional method. CONCLUSIONS: Many children admitted to the hospital with diarrhoea, vomiting or fever were not assigned discharge codes for acute gastroenteritis. Consequently, standard indirect methods missed a substantial number of rotavirus-associated hospitalisations, thereby underestimating the absolute number of children who could potentially benefit from vaccination.

Self-rated health as a tool for estimating health-adjusted life expectancy among patients newly diagnosed with localized prostate cancer: a preliminary study.

PURPOSE: Localized prostate cancer (LPC) patients are faced with numerous treatment options, including observation or watchful waiting. The choice of treatment largely depends on their baseline health-adjusted life expectancy (HALE). By consensus, physicians recommend treatment if the patient's HALE is ten or more years. However, the estimation of HALE is difficult. Although subjective by nature, self-rated health (SRH) is a robust predictor of mortality. We studied the usefulness of SRH in estimating HALE in patients who are considering treatment for LPC. METHODS: A total of 144 LPC patients from a large urology private practice in Norfolk, Virginia, were surveyed before they had chosen a treatment option. RESULTS: HALE determined by SRH correlated well with objective health measures and was higher than age-based life expectancy by an average of 2 years. The observed difference in life expectancy due to SRH adjustment was higher among patients with a better socioeconomic and health profile. CONCLUSIONS: SRH is an easy-to-use indicator of HALE in LPC patients. A table for HALE estimation by age and SRH is provided for men aged 70-80 years. Additional research with larger samples and prospective study designs are needed before the SRH method can be used in primary care and urology settings.

A randomized, double-blind study comparing the efficacy of selenium sulfide shampoo 1% and ciclopirox shampoo 1% as adjunctive treatments for tinea capitis in children.

Our objective was to compare the efficacy of selenium sulfide shampoo 1% and ciclopirox shampoo 1% as adjunctive treatments for tinea capitis in children. Forty children aged 1-11 years with clinically diagnosed tinea capitis were randomized to receive selenium sulfide shampoo 1% or ciclopirox shampoo 1% twice a week as adjuncts to an 8-week course of ultramicronized griseofulvin dosed at 10-12 mg/kg/day. At weeks 2, 4, and 8, subjects returned to the clinic for evaluation and scalp cultures. Subjects then returned for follow-up visits 4 weeks after completing treatment. Overall, by 8 weeks, 30 of 33 (90.9%) treated children demonstrated mycological cure. Selenium sulfide shampoo 1% and ciclopirox shampoo 1% were equally effective as adjunctive treatments for tinea capitis in children in our study.

The presence of bruising associated with fractures.

OBJECTIVE: To determine the occurrence of bruising near the site of fracture in a group of children with inflicted fractures. DESIGN: Case series. SETTING: Two children's hospitals. PARTICIPANTS: Suspected child abuse victims with fractures. MAIN OUTCOME MEASURE: The presence of bruising and fracture in a single body region or appendage. RESULTS: The study included 192 children with inflicted fractures. No bruising was found in 111 (57.8%) of the study participants. Forty patients (20.8%) had bruising near the site of at least 1 fracture. Of these, bruising or subgaleal hematoma near the site of a skull fracture was seen most often, in 43.3% of patients. Bruising in association with extremity fractures was seen much less commonly, ranging from 3.8% (n = 2) of children with tibia fracture to 16.7% (n = 1) of children with fibula fracture. Rib fractures also were associated uncommonly with bruising. When skull fractures are excluded, 45 (8.1%) of 555 fractures had bruising near the fracture site, in 13 (6.8%) patients. CONCLUSIONS: In children with inflicted skeletal trauma, the fractured bones that most frequently have associated bruising are the skull bones. The presence of bruising near the fracture site is uncommon in extremity or rib fractures.

Inflicted skeletal trauma: the relationship of perpetrators to their victims.

OBJECTIVE: Although inflicted skeletal trauma is a very common presentation of child abuse, little is known about the perpetrators of inflicted skeletal injuries. Studies exist describing perpetrators of inflicted traumatic brain injury, but no study has examined characteristics of perpetrators of inflicted skeletal trauma. METHODS: All cases of suspected child physical abuse evaluated by the child abuse evaluation teams at Vanderbilt University Medical Center (January 1996 to August 2000) and at the Children's Hospital at Denver (January 1996 to December 1999) were reviewed for the presence of fractures. All children with inflicted fractures were entered into the study, and demographic data, investigative data, and identity of perpetrators were collected. RESULTS: There were a total of 630 fractures for 194 patients. The median number of fractures per patient was 2, and the maximum was 31. Sixty-three percent of children presented with at least one additional abusive injury other than the fracture(s). Perpetrators were identified in 79% of the cases. Nearly 68% of the perpetrators were male; 45% were the biological fathers. The median age of the children abused by males (4.5 months) significantly differed from the median age of those abused by females (10 months) (p=.003). CONCLUSION: In the cases where a perpetrator of inflicted fractures could be identified, the majority were men, most commonly the biological fathers. Children injured by men were younger than those injured by women.

Measuring international normalized ratios in long-term care: a comparison of commercial laboratory and point-of-care device results.

OBJECTIVES: Point-of-care (POC) anticoagulation testing devices can potentially improve warfarin therapeutics in long-term care; however, there is variable accuracy reported for these devices and scant data when used in older adults. Accordingly, we undertook this study to determine the accuracy of a POC device (Hemosense INratio) in long-term care settings and examine factors associated with discrepant results. DESIGN: Case series. SETTING: Two, demographically comparable continuing-care retirement communities in the Southeastern United States. PARTICIPANTS: Long-term (nursing home and assisted living) residents with atrial fibrillation, venous thromboembolism, or prior cerebrovascular accident (16 at site 1; 8 at site 2). MEASUREMENTS: INR results calculated by the Hemosense device were compared with those determined by venipuncture-collected samples run in commercial laboratories. Patient demographic and clinical data were collected, as was performance by tester. RESULTS: Correlation varied between sites and, at site 1, between testers. Accuracy at site 1 was comparable to published reports for 2 of the 3 testers, with rather disconcerting discrepancy rates of 17.8% and 23.1%. However, correlation for the third tester was much better, with only a 7% discrepancy rate based on clinician rating of Hemosense-Reference lab differences. Correlation at site 2 was considerably worse than site 1, to the point that the Hemosense could not be safely adopted. CONCLUSION: POC devices may not be appropriate for commercial laboratory tests substitution without prior performance evaluation. Running POC INRs concurrent with laboratory-determined INRS can determine test reliability. Timing of Hemosense testing in relation to when laboratory INRs were drawn is one likely explanation for our results, although user differences may also contribute significantly. Further research in larger, more diverse populations, using a variety of POC devices, and with direct comparison of older and younger patients is needed.

Reliability of a standardized protocol to calculate cross-sectional chest area and severity indices to evaluate pectus excavatum.

PURPOSE: In evaluating the impact of surgical repair of pectus excavatum, the Haller index developed for preoperative decision-making purposes may be inadequate to quantify postoperative changes in shape of the chest. Individual patients may also have chest characteristics that impact the success of repair, many of which would be unlikely to be measured by the Haller index alone. We have developed a protocol that measures the cross-sectional chest area and the asymmetry index along with the Haller index to more completely quantify the nature of the deformity. The purpose of this study was to determine the reliability of this protocol in the interpretation of chest computed tomography images from multiple sites. The protocol was developed as part of a multicenter study of clinical outcomes after surgical repair of pectus excavatum. METHODS: Two radiologists independently selected 5 images from each of 32 computed tomography scans from multicenter study participants according to the protocol. A digitizer was used to measure the diameters and cross-sectional areas of the images selected; these results were used to calculate the Haller and asymmetry indices. The protocol was tested for intradigitizer and interradiologist reliability. Using the Haller and asymmetry indices, we also assessed agreement between radiologists classifying patients as abnormal. RESULTS: Agreement was uniformly high for all comparisons (all Lin's concordance coefficients >0.99 and all Cohen's kappa's >0.85, all agreement on classification of patients >95%) indicating almost perfect agreement. Disagreement on classification of patients using the Haller and asymmetry index was at the cut points for abnormality. CONCLUSION: The protocol was found to be a highly reliable method for deriving the cross-sectional area of the chest and the Haller and asymmetry indices and for classifying patients for surgical eligibility. Borderline cases should be examined carefully to determine the appropriateness of surgical intervention. Cross-sectional area can be measured reliably using this protocol and thus may be useful in quantifying the success of surgical intervention.

Prevalence and genetic characterization of caliciviruses among children hospitalized for acute gastroenteritis in the United States.

Human calicivirus was the first recognized viral agent causing gastroenteritis in humans. Norovirus (NV) and Sapovirus (SV), two genera within the Caliciviridae family, cause epidemic and endemic acute gastroenteritis in children and adults. The role of these viruses as a cause of sporadic acute gastroenteritis in young children requiring hospitalization is not well established. The aim of this study was to assess the prevalence and genetic diversity of caliciviruses among children hospitalized with symptoms of acute gastroenteritis. Stool samples were collected over 2 years from symptomatic children (N=1840) up to 5 years of age at three pediatric hospitals in the US. Overall, 156 (8.5%) samples were CV-positive, 131 (7.1%) confirmed by sequencing to be NV and 25 (1.4%) confirmed to be SV. Sequences of RT-PCR-amplified polymerase gene segments were analyzed using distance, maximum likelihood and parsimony algorithms. Phylogenetic analysis of 97 NV sequences showed that seven strains were in genogroup I, 86 strains were in genogroup II and four strains were not in genogroup I, II, or III, likely representing three new NV genogroups IV, VI and VII. Genogroup I and genogroup II strains were in 12 new genetic clusters, three in genogroup I and nine in genogroup II. Within genogroups I and II, most (98%) NV strains were in genetic clusters with no known prototype in GenBank. Phylogenetic analysis of 24 SV strains showed that half grouped with the London/92 strain in one genogroup and the remainder in three other proposed genogroups, one novel. In conclusion, NV and SV were frequent causes of hospitalization for acute gastroenteritis in young children and infecting strains were highly diverse, including newly recognized genogroups and genetic clusters within known genogroups.

Prevalence of scalp scaling in prepubertal children.

OBJECTIVE: To determine the prevalence and most common etiologies of scalp scaling in infants and prepubertal children and the specificity of head and neck lymphadenopathy for the diagnosis of tinea capitis associated with scalp scaling. DESIGN/METHODS: A cross-sectional study of 300 children, 200 from an urban general pediatric practice and 100 from 2 urban pediatric dermatology practices, was conducted. Half of the subjects were <2 years old, and half were 2 to 10 years old. Demographic data, medical history, and clinical data noting the presence of scalp scaling and other scalp signs and symptoms, as well as adenopathy of the head and neck, were collected. RESULTS: Scalp scaling was seen in 66 (22%) children. There was an insignificantly higher prevalence of scalp scaling in those <2 years old compared with the 2- to 10-year-old group. In those <2 years old with scalp scaling, the most common diagnoses were seborrheic dermatitis (thick, adherent, greasy scale predominantly in the frontal and/or vertex areas of the scalp) and atopic dermatitis/eczema. Among those 2 to 10 years old with scalp scaling, the most common diagnoses were nonspecific (fine, white) scaling, seborrheic dermatitis, and atopic dermatitis/eczema. Nine (3%) patients were culture-positive for a dermatophyte, all of whom were black, and grew Trichophyton tonsurans. More than half (52.7%) of all patients had head and neck adenopathy. The presence of posterior nodes was significantly associated with atopic dermatitis/eczema and marginally associated with a positive dermatophyte culture. The presence of scalp scaling plus posterior adenopathy was significantly associated with seborrheic dermatitis and a positive dermatophyte culture in the entire study population and with atopic dermatitis in the pediatric dermatology clinics. CONCLUSIONS: Scalp scaling was common in children 0 to 10 years old. Infantile-type seborrheic dermatitis was noted in both age groups: it was 3 times as likely in children <2 years old (18%) than in those 2 to 10 years old (6%). Contrary to traditional teaching, seborrheic dermatitis can be found in preadolescent children. Atopic dermatitis/eczema was associated with scalp scaling in both age groups. Head and neck adenopathy was very common and nonspecific for any 1 diagnosis. Posterior adenopathy with concurrent scalp scaling was significantly associated with seborrheic dermatitis, a positive dermatophyte culture, and atopic dermatitis. In this nonselected pediatric population, scalp scaling with adenopathy was not associated exclusively with tinea capitis.