Progressive severe visual loss after long-term withdrawal from thioridazine treatment.

PURPOSE: To report advanced thioridazine-induced retinopathy in a 50-year-old woman with evidence of progressive severe loss of vision over 30 years after withdrawal from thioridazine treatment. METHODS: The ocular fundus examination revealed areas of retinal pigment epithelium (RPE) clumping as well as generalized atrophy of the RPE and choroid. The patient experienced visual loss to the level of no light perception in both eyes despite the fact that the funduscopic appearances of her optic nerves and retinal vasculature remained relatively normal. CONCLUSIONS: This case demonstrates that severe progressive visual loss can occur several years after the cessation of chronic thioridazine treatment.

Randomized, controlled study of low-dose 5-fluorouracil in primary trabeculectomy.

PURPOSE: To report a randomized clinical trial of postoperative subconjunctival injections of low-dose 5-fluorouracil in patients undergoing primary trabeculectomy. METHODS: In a prospective, randomized clinical trial, 40 eyes of 40 patients were randomized to the low-dose 5-fluorouracil group and received three subconjunctival injections of 5 mg each over 11 postoperative days, and 40 eyes of 40 patients were randomized to trabeculectomy without 5-fluorouracil. RESULTS: Mean (+/-SD) preoperative and 1-year postoperative intraocular pressures in the 5-fluorouracil group were 26.9 (+/-9.5) and 15.3 (+/-5.8) mm Hg, respectively. In the control group these were 25.9 (+/-8.1) mm Hg, and 15.8 (+/-5.1) mm Hg, respectively. The patients who received 5-fluorouracil had a mean reduction in intraocular pressure of 11.5 (+/-9.1) mm Hg at a median follow-up of 52.3 weeks. The control group had a mean reduction in intraocular pressure of 10.2 (+/-8.7) mm Hg at a median follow-up of 52.6 weeks. These differences were not statistically significant. CONCLUSIONS: Three postoperative subconjunctival 5-fluorouracil injections of 5 mg each after trabeculectomy in eyes at low risk for failure had no statistically or clinically significant effect on reduction of intraocular pressure with 1-year follow-up. Enhancement of success in this group of patients may require a larger total dose of 5-fluorouracil.

Comparison between Tendency-Oriented Perimetry (TOP) and octopus threshold perimetry.

OBJECTIVE: To compare the results obtained by a new ultra-short automated perimetry test known as Tendency-Oriented Perimetry (TOP), which is an algorithm based on estimation of thresholds from information gathered from adjacent points with those obtained by a standard bracketing approach. TOP is designed to save up to 1/5 of the time taken by standard strategy by presenting each stimulus once on each location (instead of 4 to 6 times per location with the standard technique) and reaching a final threshold estimate by gathering information from responses to adjacent locations. DESIGN: Prospective, multicenter, observational comparative case series. PARTICIPANTS/METHODS: Four academic institutions provided data from testing 57 subjects, 15 with a normal ocular exam and 42 with a variety of visual field abnormalities. A total of 228 visual fields were analyzed. Two examinations of standard thresholding testing (Octopus program 32) and two examinations of the TOP program were obtained in each subject the same day. MAIN OUTCOME MEASURES: Comparison of global indices such as mean deviation (MD), square root of loss of variance (sLV), topographical defects, point by point differences, reproducibility, sensitivity/specificity, and time required to complete the test. RESULTS: Correlation coefficient of global indices between both tests was high, with mean deviation of r = 0.97 (SE[YX] +/- 1.65 decibels) and square root of loss variance of r = 0.93 (SE[YX] +/- 1.10 dB). Mean sensitivity tended to be 1 dB higher while MD tended to be 1 dB lower with TOP strategy. Reproducibility was equally good between both tests for threshold determination as well as for all global indices (MS, MD per quadrant, and LV). Cluster criteria for abnormality demonstrated TOP versus 32: sensitivity of 89/87; specificity of 90/77; positive predictive value of 96/91; negative predictive value of 75/68; and accuracy of 89/84. Mean time taken by this beta version of TOP was 4.05 minutes standard deviation +/- 0.55 versus the standard 32 version taking 14.65 minutes standard deviation +/- 3.75. CONCLUSIONS: TOP was four times faster than the traditional full-threshold technique and was successful in detecting visual field abnormalities. Defects with TOP tended to be smaller, shallower, and with softer edges than with standard approach. TOP could prove an alternative to traditional perimetric techniques.

Profile of uninsured children in the United States.

OBJECTIVES: To describe the demographic characteristics, utilization of medical services, and health status of uninsured children compared with insured children in the United States and to assess the factors associated with lack of health insurance among children. An estimated 8 million children in the United States are uninsured. Medicaid expansions and tax credits have had little impact on the overall problem. An understanding of the characteristics of uninsured children is essential for the design of appropriate outreach and enrollment strategies, benefit packages, and health care provision arrangements for uninsured children. METHODS: Analysis of the 1988 Child Health Supplement of the National Health Interview Survey. RESULTS: Diverse groups of children in the United States lack health insurance. Residence in the South (odds ratio [OR], 2.3) and West (OR, 1.9. [corrected]) and being poor (OR, 2.2) or nearly poor (OR, 2.1) are independently associated with being uninsured. Substantial differences in both sources of care and utilization of medical services exist between uninsured and insured children. Uninsured children lack usual sources of routine care (OR, 3.1) and sick care (OR, 3.8) and also lack appropriate well-child care (OR, 1.5) compared with insured children. Neither being in fair or poor health nor emergency department use are significant independent predictors of being uninsured among children. Children who have a chronic disease, such as asthma, face difficulties of access to care and utilize substantially fewer outpatient and inpatient services. CONCLUSIONS: Universal health insurance, rather than efforts directed at specific groups, appears to be the only way to provide health insurance for all US children. Uninsured and insured children reveal marked discrepancies in access to and utilization of medical services, including preventive services, but have similar rates of chronic health conditions and limitations of activity. Uninsured children do not appear to form a population that will incur higher mean annual expenditures for medical care compared with insured children.

Acetaminophen analgesia in neonatal circumcision: the effect on pain.

OBJECTIVE: Recognizing the concerns about the use of local anesthesia in neonatal circumcision, a painful procedure usually performed without analgesia or anesthesia, we undertook a study of acetaminophen for pain management of this procedure. DESIGN: A prospective, randomized, double-blind, placebo-controlled, clinical trial of acetaminophen analgesia in 44 healthy full-term neonates undergoing circumcision was conducted. Beginning 2 hours before Gomco circumcision, neonates received either acetaminophen (15 mg/kg per dose, 0.15 mL/kg per dose) or placebo (0.15 mL/kg per dose) every 6 hours for 24 hours. Neonates were monitored intraoperatively for changes in heart rate, respiratory rate, and crying time. Postoperative pain was assessed at 30, 60, 90, 120, 360 minutes, and 24 hours using a standardized postoperative comfort scoring system. Feeding behavior was also assessed before and after circumcision by nursing observation. RESULTS: Neonates in both groups showed significant increases in heart rate, respiratory rate, and crying during circumcision with no clinically significant differences observed between the groups. Postoperative comfort scores showed no significant differences between the groups until the 360-minute postoperative assessment, at which time the acetaminophen group had significantly improved scores (P < .05). Feeding behavior deteriorated in breast- and bottle-fed neonates in both groups, and acetaminophen did not seem to influence this deterioration. CONCLUSIONS: This study confirms that circumcision of the newborn causes severe and persistent pain. Acetaminophen was not found to ameliorate either the intraoperative or the immediate postoperative pain of circumcision, although it seems that it may provide some benefit after the immediate postoperative period.

Predictors of early grade retention among children in the United States.

BACKGROUND: Despite increasing concerns regarding school readiness, little is known about child health correlates of early school failure among the general child population. The results of this study, conducted to investigate health and social factors associated with early grade retention in a nationally representative sample of children in the United States, are reported here. DESIGN: Analyses of data derived from interviews with parents of 9996 children ages 7 to 17 years who participated in the Child Health Supplement to the 1988 National Health Interview Survey. MAIN OUTCOME MEASURES: History of repeating kindergarten or first grade. RESULTS: Nationally, 7.6% of children repeated kindergarten or first grade. In a logistic regression model, factors independently associated with increased risk of grade retention were: poverty [Odds Ratio (OR) 1.7, 95% confidence interval (CI) 1.4, 2.1], male gender (OR 1.5, CI 1.3, 1.9), low maternal education (OR 1.4, CI 1.1, 1.8); deafness (OR 1.9, CI 1.4, 2.6), speech defects (OR 1.7, CI 1.1, 2.6), low birth weight (OR 1.6, CI 1.2, 2.2), enuresis (OR 1.6, CI 1.1, 2.2), and exposure to household smoking (OR 1.4, CI 1.1, 1.7). High maternal education (OR 0.6 CI 0.4, 0.9) and residence with both biological parents at age 6 years (OR 0.7, CI 0.6, 0.9) were independently associated with a decreased risk of retention. Recurrent otitis media, black race, and low maternal age, although associated with early grade retention in bivariate analyses, were not independently associated with grade retention in a model that controls for these other factors and for the age cohort of the child. Although omitted from the above predictive model because of uncertainty about its temporal relation to early grade retention in this dataset, behavior problems at the time of interview have a strong independent association (OR 1.9, CI 1.5, 2.5) with prior early retention. CONCLUSIONS: This is the first study that uses national data to investigate how health and social factors individually and collectively contribute to early grade retention. It demonstrates that early retention is common, that a number of extremely common child health problems are independently associated with it, and that the magnitude of the heightened risk associated with these problems is similar to that of many of the well-recognized and difficult to change family and social risk factors for early retention. The successful implementations of Pub L 99-457 (The Education for All Handicapped Children Act Amendments of 1986) services in communities nationwide, and the improvement in the educational performance of large numbers of children will be facilitated by pediatricians' advocacy and surveillance for problems that place children at risk for educational failure, and by effective referral to and collaboration with nonpediatric child and family services.

Infant formula distribution and advertising in pregnancy: a hospital survey.

A survey was conducted at a 526-bed community hospital in Rochester, New York, to determine the prevalence of formula advertising and distribution during pregnancy to 136 consecutive intrapartum patients. Women answered a questionnaire about their choice of infant feeding methods and prenatal exposure to formula advertising. Of those who received printed information on infant feeding, 78 percent reported that it was published by a formula company, and 65 percent recalled receiving offers for free formula during their pregnancy. The likelihood of having received such offers was the same in women who planned to breastfeed as in those who planned to formula feed. Thirty-eight percent of women obtained formula through a free offer before their infant's birth. Women who were privately cared for were more likely to have received offers for free formula (p < 0.001) than were women cared for in hospital-affiliated clinics. Ninety percent of women who received free formula prenatally reported their prenatal caregiver as a source of samples. Of samples that women obtained prenatally, 93 percent were from companies that advertise only indirectly through hospitals and physicians, whereas 7 percent were from companies that advertise directly to patients. The prevalence of formula company advertising during the prenatal care of women who deliver in this hospital is high. The continued participation of prenatal caregivers in promotion efforts of formula companies provides a negative or mixed message about the importance of breastfeeding and may be a barrier to its success.

Failure of Birth Data to Predict Early School Difficulties Among Inner-city First Graders.

OBJECTIVES.: To determine a set of perinatal characteristics that predict school difficulties in inner-city children by comparing first graders requiring remediation with first graders progressing normally. METHODS.: In a case-control study, maternal surveys about perinatal characteristics were completed for 74 of 90 remedial pre-first and 62 of 90 randomly selected first graders in the Rochester, NY, City School District. RESULTS.: Pre-first graders, as compared with first graders, were more likely to have had birth weights <2,500 g (27% versus 6%). During pregnancy, their mothers were more likely to have been unemployed (73% versus 50%), to have received WIC (68% versus 50%), to have been covered by Medicaid (58% versus 37%), and to have received late or no prenatal care (9% versus 2%). Of these factors, only low birth weight was independently associated with remedial kindergarten placement. CONCLUSION.: Potential risk factors, unfortunately, were fairly prevalent in both groups of inner-city children. While the remedial group was shown to be at greater risk, these findings have little utility in identifying subsets most likely to require remediation at school entry. Because resources aimed at preventing the long-term consequences of early school failure are limited, better means of identifying educational risk at an early age are urgently needed.