The view from the horizon: strategic partnerships of public health, academic medical centers, and managed care.

The organization and operation of public health departments must change if they are to participate in the evolving health system. Strategic partnerships with academic medicine, academic medical centers, and managed care organizations offer an opportunity to establish and sustain these new roles. A rationale for collaboration and description of the assets each organization contributes to the partnership is described. The experience of the authors in developing such strategic partnerships and other examples from across the country is presented.

Supraglottitis in three young infants.

Three case histories of young infants with supraglottitis are presented. At this age, supraglottitis rarely occurs. Atypical features, as compared to older children, include a viral prodrome, lack of fever, stomatitis, and negative blood cultures. Although viral supraglottitis has been previously reported, this is the first report of epiglottitis associated with parainfluenza virus.

Cricoarytenoiditis as a cause of acute airway obstruction in children.

A 4-1/2-year-old girl with a one-year history of juvenile rheumatoid arthritis was admitted with severe respiratory distress requiring endotracheal intubation. Arthritis of the cricoarytenoid joint was diagnosed and she responded well to intubation and high-dose steroids. Although well described in adults, this is only the third case report of a child afflicted with arthritis of the cricoarytenoid joint.

Parental perception of urgency and utilization of pediatric emergency services.

Emergency Room utilization has increased dramatically in recent years. Parental perception of urgency may be one factor that influences utilization of pediatric emergency services, yet little is understood about factors influencing this perception. The goal of this study was to determine if the perception of urgency is a critical factor in the decision of a parent to seek care in an emergency room, if demographic and access factors influence parental perception of urgency, and whether there is agreement of urgency rating by parent and physician. One hundred and one parents were interviewed to determine background demographic and access factors and perception of urgency. Physician and parental urgency was evaluated on a 5 level scale. Chi-square analysis was used to determine association between demographic and access factors and parental urgency ratings. Pearson product moment correlation was used to determine agreement between parent and physician urgency ratings. The majority of visits were acknowledged by both parents and physicians to be non-emergent. Fourteen (13.9%) and 10 (9.9%) of parents and physicians rated the visits as emergent (levels 1 and 2) while 65 (64.4%) parents and 76 (75.3%) physicians rated the visits as nonemergent. No association between demographic or access variables and parental perception of urgency was demonstrated.

Apnea of infancy. Approach to evaluation and management.

The sudden, silent, unobserved death during sleep of an apparently healthy infant strikes about 8,500 children each year in this country. Once called crib death, sudden infant death syndrome (SIDS) has left a trail of grieving parents and baffled pathologists who could find no specific cause at autopsy. One current theory links apnea of infancy to this mystery killer. In the first article of this series on pediatric problems, Dr Goldhagen, who directs an infant apnea evaluation program in Minneapolis, discusses a practical approach to identifying and managing children at risk for apnea of infancy and offers suggestions on the use of cardiorespiratory monitoring in the hospital and in the home.

Croup: pathogenesis and management.

Croup syndromes are common in children, most frequently being infectious in origin. Children present with a slow progression of inspiratory and expiratory stridor and a croupy, "barking seal" cough. Children are variably febrile and with progression of disease, exhaustion, agitation, cyanosis and air hunger may develop. The evaluation of the patient must focus on the degree of respiratory distress and associated findings. Epiglottitis and foreign body aspiration must be excluded. Management is primarily dependent upon administration of humidified air. Children with moderate to severe croup benefit from racemic epinephrine and steroids. Admission is indicated in children with stridor at rest, evidence of exhaustion, toxicity or respiratory distress. Active airway intervention is rarely required but may be life saving if obstruction develops.