Infantile Henoch-Schönlein purpura.

Henoch-Schönlein purpura is a common cause of vasculitis in children. This condition is unusual in infants and children younger than 2 years. We describe a 4-month-old infant with infantile Henoch-Schönlein purpura and review the clinical spectrum, differential diagnoses, and the histopathologic features of the disease. Its relations to Henoch-Schönlein purpura in older children are discussed.

Office laboratory procedures, office economics, patient and parent education, and urinary tract infection.

This review updates our readers on four important areas of office practice: office laboratory procedures, office economics, patient and parent education, and urinary tract infection. Michael Aldous reviews the recent literature on office laboratory procedures, which includes a report on the ongoing heated discussion of the Clinical Laboratory Improvement Amendments, an update of recent studies on new and better rapid streptococcal tests, and improved methods for urinalysis. Rickey Williams provides a report on office economics that includes a discussion of the effects of capitation, how preventive care can be cost effective, and the future prospects for greatly expanded office computerization. Burris Duncan discusses patient and parent education with an in-depth review of the potential economic value of a full implementation of the American Academy of Pediatrics' The Injury Prevention Program, and in addition he chronicles the rapid growth and development of school-based health centers. John Ey reviews the recent literature on urinary tract infections in children, including how we can make the diagnosis, methods for preventing recurrent urinary tract infections, the most effective studies for evaluating the urinary system, and what follow-up is necessary. We hope this review will provide the pediatrician with important information to help in the care of their patients.

Office laboratory procedures, office economics, patient and parent education, and urinary tract infection.

This section updates the reader on four important areas of office practice: office laboratory procedures, office economics, patient and parent education, and urinary tract infections. Dr. Michael Aldous reviews the recent literature about office laboratory procedures, including the continued impact of the Clinical Laboratory Improvement Ammendments, what is new in the diagnosis of streptococcal pharyngitis, urinalysis improvements, the diagnosis of anemia, and which patients should undergo cholesterol screening. Dr. Rickey Williams discusses the literature on office economics, including new technology for billing and charting, whether pediatricians should bill for telephone calls, and the latest information on health care policy and the changes offices are facing with the growing managed care market. Dr. Burris Duncan reviews patient and parent education, including new apporaches to infant colic, sleep positioning for the prevention of sudden infant death, the need for the hepatitis B vaccine (which has been slowly implemented), and finally ways that pediatricians can help with parenting. Dr. John Ey discusses the recent literature on urinary tract infections in children, including better ways of making the diagnosis, whether there are any new treatment approaches for urinary tract infections, useful investigational studies for evaluating the urinary system, and how best to follow up children with infected urinary tracts. We hope that this review will help the practicing pediatrician to better care for patients and provide each of you with a greater satisfaction in delivering health care in an office setting.

Passive smoke exposure and otitis media in the first year of life. Group Health Medical Associates.

OBJECTIVE: This study examined, in a health maintenance organization population of children, the associations between parents' smoking and otitis media (OM) in their children while controlling for other known risk factors. METHODS: Healthy newborns (1246) in a large health maintenance organization were enrolled at birth, and 1013 (81%) were followed prospectively for the first year of life. Their medical records were reviewed for the diagnosis of otitis media. Information on risk factors for recurrent OM (ROM) was collected, including a number of variables related to parental smoking. RESULTS: After controlling for other known risk factors for ROM including gender, day care, other siblings in the home, parental history of hay fever, and method of feeding, it was found that heavy maternal smoking of 20 or more cigarettes per day was a significant risk factor for ROM but not for nonrecurrent otitis. Heavy maternal smoking was associated with a threefold risk for ROM if the infant weighed less than the mean at birth (3.5 kg) after controlling for other risk factors. No association was found with paternal smoking. CONCLUSIONS: Heavy maternal smoking is a significant risk factor for ROM in the first year of life. This smoking effect seems to be stronger among infants of lower birth weight.

Office laboratory procedures, economics of practice, patient and parent education, and urinary tract infection.

This review highlights recent advances in four major areas that are relevant to office practice: office laboratory procedures, economics of practice, adolescent risk-taking behavior in terms of sexually transmitted diseases, and urinary tract infections. Who should be screened for diseases and where these screening tests should be done are addressed, keeping the practicing pediatrician in mind. Next we review current office economics, including whether professional courtesy should be continued, how our practices are going to be increasingly influenced by guidelines developed by the American Academy of Pediatrics, the Clinical Laboratory Improvement Amendments, and the new Clinton Health Plan if it survives Congress, and finally how all of these issues will affect our expected income in the years ahead. As pediatricians strive to retain adolescent patients in their practices, they will need to find appropriate ways of counseling these patients concerning risk behaviors that could result in sexually transmitted diseases or HIV infections. Should we leave the comfortable confines of our offices to participate in these counseling programs for adolescents, and are there lessons from existing successful International Health Programs that we can use? Finally, urinary tract infections (UTIs) continue to be a common cause of childhood infections with possible serious long-term sequelae. Can we do a better job of diagnosing UTIs, has improved treatment become available, and is prevention of recurrences possible? Once the diagnosis has been made, how can we best evaluate these children with UTIs for underlying urologic abnormalities? It is our hope that the practicing pediatrician will be better prepared to face these issues having read this review.

Pediatric emergency training: an alternative teaching-patient care model.

We describe a cost-effective alternative to the pediatric and general emergency department (ED), the emergent/urgent care clinic (EUC). The vast majority of pediatric Medicaid-eligible patients are rerouted from the ED to the EUC, where they receive care from pediatric residents and faculty. A retrospective analysis of patient encounter forms from two EUCs was performed. The type and distribution of diagnoses at the EUCs were comparable with published data from pediatric and general EDs. The cost of care in the EUC is significantly less than that in the ED, although the educational opportunities for house staff and patients are superior to those obtained in the traditional ED setting. A patient population that historically seeks episodic care in EDs is provided with continuity of care and disease prevention through screening, guidance, and up-to-date immunizations.

The influence of preschool pertussis immunization on an epidemic of pertussis.

Between 1988 and 1989 there were 896 reported cases of pertussis in Arizona. Of the 781 investigated cases 55 were identified in children younger than 5 years of age. Thirty-five percent of children between 6 months and 5 years of age were not fully immunized; 3 infants died. Approximately 50% of infected children between 5 and 14 years of age had not received 5 doses of pertussis vaccine. Of the 413 physician respondents to a questionnaire, fully 10% do not administer pertussis vaccine to preschool children because of parental, personal or other reasons. We hypothesize that the reservoir of pertussis-susceptible older children and young adults is augmented by this omission of the fifth diphtheria-tetanus toxoids-pertussis vaccine. Newer educational and vaccine strategies are necessary to prevent epidemics of pertussis.

Varicella hepatitis without neurologic symptoms or findings.

Varicella hepatitis has been reported frequently in immunocompromised patients and occasionally in adults with varicella pneumonia and/or systemic involvement. However, hepatitis is not generally known to occur in otherwise uncomplicated varicella. Six children are described who had typical varicella in association with transient elevation of liver enzymes. No CNS abnormalities were noted, and all recovered uneventfully. Such patients have previously been described as representing stage I of Reye's syndrome. The authors postulate that hepatitis complicating varicella may well represent a distinct entity which bears no relationship to Reye's syndrome.

Recurrent group C streptococcal tonsillitis in an adolescent male requiring tonsillectomy.

A 15-year-old boy had reported episodes of tonsillitis with group C streptococci over a four-month period. The tonsillitis cleared with antibiotic therapy but was followed by a recurrence within a few days. Tonsillectomy resulted in a permanent cure and group C streptococcus was found in the tonsils. A literature search has failed to reveal similar cases and a brief review of the existing literature is given.