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The development of medical care for U.S. military families and retirees was serendipitous, a fortunate accident. The formal development of military family medical care required the evolution of three factors: the emergence of a standing army, frontiers to guard, and a peace to defend. These factors were first realized in the late 19th Century, and beginning at that point in U.S. history, seven key years highlight major milestones in the history of military family member medical care. At the same time, these years exemplify changing ideas of disease and of health care and how the physical design of clinics and hospitals reflects and impacts these ideas. The Fort Belvoir Community Hospital, which opens in 2011, exemplifies the Nation's best example of green hospital construction, patient and family centered care, and evidence-based design in a Culture of Excellence that demonstrates that military family medical care is finally "deliberate by design." [ABSTRACT FROM AUTHOR]

We conducted a single-center study at a free community testing site in Baltimore City to assess the accuracy of self-performed rapid antigen tests (RATs) for COVID-19. Self-administered BinaxNOW RATs were compared with clinician-performed RATs and against a reference lab molecular testing as the gold standard. Of the 953 participants, 14.9% were positive for SARS- CoV-2 as determined by RT-PCR. The sensitivity and specificity were similar for both self- and clinician-performed RATs (sensitivity: 83.9% vs 88.2%, P = 0.40; specificity: 99.8% vs 99.6%, P = 0.6). Subgroup comparisons based on age and race yielded similar results. Notably, 5.2% (95% CI: 1.5% to 9.5%) of positive results were potentially missed due to participant misinterpretation of the self-test card. However, the false-positive rate for RATs was reassuringly comparable in accuracy to clinician-administered tests. These findings hold significant implications for physicians prescribing treatment based on patient-reported, self-administered positive test results. Our study provides robust evidence supporting the reliability and utility of patient-performed RATs, underscoring their comparable accuracy to clinician-performed RATs, and endorsing their continued use in managing COVID-19. Further studies using other rapid antigen test brands are warranted.IMPORTANCEAccurate and accessible COVID-19 testing is crucial for effective disease control and management. A recent single-center study conducted in Baltimore City examined the reliability of self-performed rapid antigen tests (RATs) for COVID-19. The study found that self-administered RATs yielded similar sensitivity and specificity to clinician-performed tests, demonstrating their comparable accuracy. These findings hold significant implications for physicians relying on patient-reported positive test results for treatment decisions. The study provides robust evidence supporting the reliability and utility of patient-performed RATs, endorsing their continued use in managing COVID-19. Furthermore, the study highlights the need for further research using different rapid antigen test brands to enhance generalizability. Ensuring affordable and widespread access to self-tests is crucial, particularly in preparation for future respiratory virus seasons and potential waves of reinfection of SARS-CoV-2 variants such as the Omicron variant., Competing Interests: The authors declare no conflict of interest.

Controlled environment agriculture (CEA) is a rapidly growing sector that presents unique challenges and opportunities in ensuring food safety. This manuscript highlights critical gaps and needs to promote food safety in CEA systems as identified by stakeholders (n=47) at the Strategizing to Advance Future Extension andResearch (S.A.F.E.R.) CEA conference held in April 2023 at The Ohio State University's Ohio CEA Research Center. Feedback collected at the conference was analyzed using an emergent thematic analysis approach to determine key areas of focus. Research-based guidance is specific to the type of commodity, production system type, and size. Themes include the need for improved supply chain control, cleaning, and sanitization practices, pathogen preventive controls and mitigation methods and training and education. Discussions surrounding supply chain control underscored the significance of the need for approaches to mitigate foodborne pathogen contamination. Effective cleaning and sanitization practices are vital to maintaining a safe production environment, with considerations such as establishing standard operating procedures, accounting for hygienic equipment design, and managing the microbial communities within the system. Data analysis further highlights the need for risk assessments, validated pathogen detection methods, and evidence-based guidance in microbial reduction. In addition, training and education were identified as crucial in promoting a culture of food safety within CEA. The development of partnerships between industry, regulatory, and research institutions are needed to advance data-driven guidance and practices across the diverse range of CEA operations and deemed essential for addressing challenges and advancing food safety practices in CEA. Considering these factors, the CEA industry can enhance food safety practices, foster consumer trust, and support its long-term sustainability., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 The Author(s). Published by Elsevier Inc. All rights reserved.)

The El Niño-Southern Oscillation (ENSO) shapes extreme weather globally, causing myriad socioeconomic impacts, but whether economies recover from ENSO events and how anthropogenic changes to ENSO will affect the global economy are unknown. Here we show that El Niño persistently reduces country-level economic growth; we attribute $4.1 trillion and $5.7 trillion in global income losses to the 1982-83 and 1997-98 El Niño events, respectively. In an emissions scenario consistent with current mitigation pledges, increased ENSO amplitude and teleconnections from warming are projected to cause $84 trillion in 21st-century economic losses, but these effects are shaped by stochastic variation in the sequence of El Niño and La Niña events. Our results highlight the sensitivity of the economy to climate variability independent of warming and the potential for future losses due to anthropogenic intensification of such variability.

Increased extreme heat is among the clearest impacts of global warming, but the economic effects of heat waves are poorly understood. Using subnational economic data, extreme heat metrics measuring the temperature of the hottest several days in each year, and an ensemble of climate models, we quantify the effect of extreme heat intensity on economic growth globally. We find that human-caused increases in heat waves have depressed economic output most in the poor tropical regions least culpable for warming. Cumulative 1992-2013 losses from anthropogenic extreme heat likely fall between $5 trillion and $29.3 trillion globally. Losses amount to 6.7% of Gross Domestic Product per capita per year for regions in the bottom income decile, but only 1.5% for regions in the top income decile. Our results have the potential to inform adaptation investments and demonstrate how global inequality is both a cause and consequence of the unequal burden of climate change.

SARS-CoV-2 continues to develop new, increasingly infectious variants including delta and omicron. We evaluated the efficacy of the Abbott BinaxNOW Rapid Antigen Test against Reverse Transcription PCR (RT-PCR) in 1,054 pediatric participants presenting to a high-volume Coronavirus Disease 2019 (COVID-19) testing site while the delta variant was predominant. Both tests utilized anterior nares swabs. Participants were grouped by COVID-19 exposure and symptom status. 5.2% of samples tested positive by RT-PCR for SARS-CoV-2. For all participants, sensitivity of the BinaxNOW was 92.7% (95% CI 82.4%-98.0%), and specificity was 98.0% (95% CI 97.0%-98.8%). For symptomatic participants, positive predictive value (PPV) was 72.7% (95% CI 54.5%-86.7%) and negative predictive value (NPV) was 99.2% (95% CI 98.2%-100%). Among asymptomatic participants, PPV was 71.4% (95% CI 53.7%-85.4%) and NPV was 99.7% (95% CI 99.0%-100%). Our reported sensitivity and NPV are higher than other pediatric studies, potentially because of higher viral load from the delta variant, but specificity and PPV are lower. IMPORTANCE The BinaxNOW rapid antigen COVID-19 test had a sensitivity of nearly 92% in both symptomatic and asymptomatic children when performed at a high-throughput setting during the more transmissible delta variant dominant period. The test may play an invaluable role in asymptomatic screening and keeping children safe in school.

In May 2020, Baltimore City, Maryland, implemented the Lord Baltimore Triage, Respite, and Isolation Center (LBTC), a multiagency COVID-19 isolation and quarantine site tailored for people experiencing homelessness. In the first year, 2020 individuals were served, 78% completed isolation at LBTC, and 6% were transferred to a hospital. Successful isolation can mitigate outbreaks in shelters and residential recovery programs, and planning for sustainable isolation services integrated within these settings is critical as the COVID-19 pandemic continues. ( Am J Public Health . 2022;112(6):876-880. https://doi.org/10.2105/AJPH.2022.306778).

Rapid antigen tests are simple to perform and provide results within 15 min. We describe our implementation and assess performance of the BinaxNOW COVID-19 Antigen Test (Abbott Laboratories) in 6,099 adults at a self-referred walk-up testing site. Participants were grouped by self-reported COVID-19 exposure and symptom status. Most (89%) were asymptomatic, of whom 17% reported potential exposure. Overall test sensitivity compared with reference laboratory reverse-transcription [RT] PCR testing was 81% (95% confidence interval [CI] 75%, 86%). It was higher in symptomatic (87%; 95% CI 80%, 91%) than asymptomatic (71%; 95% CI 61%, 80%) individuals. Sensitivity was 82% (95% CI 66%, 91%) for asymptomatic individuals with potential exposure and 64% (95% CI 51%, 76%) for those with no exposure. Specificity was greater than 99% for all groups. BinaxNOW has high accuracy among symptomatic individuals and is below the FDA threshold for emergency use authorization in asymptomatic individuals. Nonetheless, rapid antigen testing quickly identifies positive among those with symptoms and/or close contact exposure and could expedite isolation and treatment. IMPORTANCE The BinaxNOW rapid antigen COVID-19 test had a sensitivity of 87% in symptomatic and 71% asymptomatic individuals when performed by health care workers in a high-throughput setting. The performance may expedite isolation decisions or referrals for time-sensitive monoclonal antibody treatment in communities where timely COVID PCR tests are unavailable.

Background: Vomiting, diarrhea, and severe dehydration are common manifestations of Ebola virus disease (EVD), leading to its high mortality. Mortality is especially high in patients older than 45 years, younger than 5 years, and in pregnant women and their fetuses. The majority of patients with EVD are not able to tolerate the quantities of oral hydration solutions necessary to rehydrate properly. Although some have speculated that IV and intraosseous lines are not practical in the austere, resource-constrained settings of an Ebola treatment unit during an epidemic, it is necessary to provide parenteral fluids and electrolyte replacements to significantly decrease mortality. Due to the inability to spend long periods of time working in hot environments wearing personal protective equipment, it is necessary to maximize the use of rapidly obtainable and safe parenteral access., Case Report: The authors present a case of a 9-month-old patient with EVD in Sierra Leone in whom an intraosseous line was lifesaving. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Emergency physicians respond to international crises, such as the most recent Ebola epidemic in West Africa. It is important for such responders, as well as their responding organizations, to know and understand that intraosseous access is an important and safe modality to use in patients with EVD and in the austere settings often found in disaster settings., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Background: Emesis can be triggered by cough in children, and cough is a common symptom of asthma., Objective: To explore the association between posttussive emesis and asthma in the pediatric population., Methods: A questionnaire was distributed to parents of children between the ages of 2 and 17 years in the pediatric and allergy-immunology clinics at our institution from August 16 through November 3, 2008. Prevalence of posttussive emesis was determined and compared among children with physician-diagnosed asthma, children with no evidence of asthma, and those not formally diagnosed as having asthma but with surrogate markers suggestive of asthma. The predictive value of posttussive emesis was compared with those of known markers of asthma. The prevalence of gastroesophageal reflux and pertussis was evaluated because these conditions might also cause posttussive emesis., Results: The prevalence of posttussive emesis was 33% in our study population of 500 children. Among those with physician-diagnosed asthma (n = 122), 56% reported a history of posttussive emesis. For patients not formally diagnosed as having asthma but with surrogate markers suggestive of asthma (n = 62), 71% had a history of posttussive emesis. Both of these were significantly higher than in those with no evidence of asthma (n = 316), in whom 16% reported a history of posttussive emesis (P < .0005). Children with posttussive emesis were significantly more likely to have asthma than those without posttussive emesis (odds ratio, 7.9; 95% confidence interval, 5.2-12). Neither pertussis nor gastroesophageal reflux accounted for the degree of posttussive emesis reported., Conclusions: Posttussive emesis is more common among children with asthma than among nonasthmatic children. In children with cough and a history of posttussive emesis, asthma should be strongly considered in the differential diagnosis., (Copyright © 2011 American College of Allergy, Asthma & Immunology. Published by Elsevier Inc. All rights reserved.)

Objective: Our objective in this report was to describe the epidemiologic features of and workload associated with pediatric admissions to 12 US Army military hospitals deployed to Iraq and Afghanistan., Methods: The Patient Administration Systems and Biostatistics Activity database was queried for all local national patients <18 years of age who were admitted to deployed Army hospitals in Afghanistan and Iraq between December 2001 and December 2004., Results: Pediatric admissions during the study period were 1012 (4.2%) of 24,227 admissions, occupying 10% of all bed-days. The median length of stay was 4 days (interquartile range: 1-8 days). The largest proportion of children were 11 to 17 years of age (332 of 757 children; 44%), although 45 (6%) of 757 children hospitalized were <1 year of age. The majority (63%) of pediatric patients admitted required either general surgical or orthopedic procedures. The in-hospital mortality rate for all pediatric patients was 59 (5.8%) of 1012 patients, compared with 274 (4.5%) of 6077 patients for all adult non-US coalition patients., Conclusions: Pediatric patients with injuries threatening life, limb, or eyesight are part of the primary responsibility of military medical facilities during combat and have accounted for a significant number of admissions and hospital bed-days in deployed Army hospitals in Afghanistan and Iraq. Military medical planners must continue to improve pediatric medical support, including personnel, equipment, and medications that are necessary to treat children injured during combat operations, as well as those for whom the existing host nation medical infrastructure is unable to provide care.

Objective: The goal was to determine whether home asthma telemonitoring with store-and-forward technology improved outcomes, compared with in-person, office-based visits., Methods: A total of 120 patients, 6 to 17 years of age, with persistent asthma were assigned randomly to the office-based or virtual group. The 2 groups followed the same ambulatory clinical pathway for 12 months. Office-based group patients received traditional in-person education and case management. Virtual group patients received computers, Internet connections, and in-home, Internet-based case management and received education through the study Web site. Disease control outcome measures included quality of life, utilization of services, and symptom control., Results: A total of 120 volunteers (45 female) were enrolled. The groups were clinically comparable (office-based: 22 female/38 male; mean age: 9.0 +/- 3.0 years; virtual: 23 female/37 male; mean age: 10.2 +/- 3.1 years). Virtual patients had higher metered-dose inhaler with valved holding chamber technique scores than did the office-based group at 52 weeks (94% vs 89%), had greater adherence to daily asthma symptom diary submission (35.4% vs 20.8%), had less participant time (636 vs 713 patient-months), and were older. Caregivers in both groups perceived an increase in quality of life and an increase in asthma knowledge scores from baseline. There were no other differences in therapeutic or disease control outcome measures., Conclusions: Virtual group patients achieved excellent asthma therapeutic and disease control outcomes. Compared with those who received standardized office-based care, they were more adherent to diary submission and had better inhaler scores at 52 weeks. Store-and-forward telemedicine technology and case management provide additional tools to assist in the management of children with persistent asthma.

Background: Studies conducted in adults have suggested that patients who use a metered-dose inhaler/holding chamber spacer (MDI/S) and dry powder inhaler (DPI) concurrently will have poorer MDI/S technique than that of patients who use MDI/S exclusively. To our knowledge, as of August 31, 2006, no studies have been performed in pediatric patients., Objective: To compare MDI/S technique scores of children using only MDI/S with scores of those using both MDI/S and DPIs., Methods: The MDI/S technique of children aged 6-17 years, with persistent asthma, recruited from a general pediatric practice population for an asthma intervention study project was scored using a standardized checklist. MDI/S scores of children who were being treated with maintenance and rescue medication delivered only by MDI/S were compared with those treated with both MDI/S (rescue) and DPI (maintenance). Scores lower than 70% were considered to be inadequate., Results: A total of 117 patients (73 male, 44 female), aged 9.70 +/- 3.1 years (mean +/- SD), with persistent asthma, participated in the study. There were 83 children (54 male, 29 female, age 9.4 +/- 3.2 y) in the MDI/S only group and 34 (19 male, 15 female, age 10.3 +/- 2.9 y) in the MDI/S + DPI group. In the MDI/S + DPI group, Diskus was the DPI used for 32 patients, and Turbuhaler was used by 2 children. Sixteen patients had severe persistent asthma, 80 had moderate persistent asthma, and 21 had mild persistent asthma as classified by National Heart Lung and Blood Institute guidelines. No difference in sex and age demographics existed; however, there was a difference in the distribution of asthma severity between groups (ie, no patients with mild persistent asthma in the MDI/S + DPI group; p < or = 0.01). Mean score for the MDI/S only group was 86 +/- 17% and, for the MDI/S + DPI group, 90.1 +/- 12% (p = 0.15). More patients in the MDI/S group had inadequate scores (18%) compared with those in the MDI/S + DPI group (3%; p < 0.05)., Conclusions: While DPI and MDI/S techniques are markedly different in several significant ways, concurrent use of these inhalers did not adversely affect MDI/S technique scores of pediatric patients with persistent asthma, compared with those using MDI/S alone. Patients in the MDI/S only group had an inadequate MDI/S score (<70%) more often than did patients in the MDI/S + DPI group.

Hospitalization of children with asthma declined at our institution between 1996 and 2000, before stabilizing for the past 5 years. The ages of children hospitalized since 2000 were examined to see if the demographics of the hospitalized population have changed to better understand why the hospitalization rate has remained the same despite continued, aggressive screening and education efforts. Data were gathered for our hospital through the Department of Defense Medical Health System Management Analysis and Reporting System (M2). The mean age (+/- SD) of children hospitalized in 2003 (2.84 +/- 2.53) was less than the mean age for 2000 and 2002 (4.85 +/- 3.7 and 4.61 +/- 4.45), respectively (p < 0.05), and more infants less than 2 years of age were hospitalized in 2003 (33/60, 55% p < 0.01) and 2004 (32/68, 47% p < 0.05) than in 2000 (19/70, 27%). The diagnosis of asthma in hospitalized infants and young children has increased over the past 5 years, suggesting better recognition and providing a new target population for intervention with early asthma controller therapy.

Background: Pediatric subspecialists are often separated from the children who need them by distance, time, or socioeconomic factors. The Electronic Children's Hospital of the Pacific is an Internet-based store-and-forward pediatric consultation system established to overcome these barriers., Objective: To characterize the use of the Electronic Children's Hospital of the Pacific and its impact on access to specialty care, the quality of the care provided, and cost savings., Design: Prospective trial., Setting: Twenty-two military treatment facilities in the Pacific., Participants: Primary care providers, pediatric consultants, and 5 reviewers., Main Outcome Measures: Consult response time, physician panel review, and evacuation cost avoidance., Results: There were 267 cases from 16 sites. The mean +/- SD response time by a consultant was 32 +/- 8 hours. The panel review deemed that the initial diagnosis was changed or modified in 15% (39/267) of the cases, the diagnostic plan was changed or modified in 21% (57/267), and the treatment plan was changed or modified in 24% (64/267) (P < .01 for all). Routine air evacuations to a tertiary care medical center were avoided in 32 cases (12%), with an estimated cost savings of $185 408., Conclusions: The Electronic Children's Hospital of the Pacific improved the quality of patient care by providing expeditious specialty consultation. Significant cost avoidance in this military pediatric population was documented. Store-and-forward Internet-based teleconsultation is an effective means of providing pediatric subspecialty consultation to a population of underserved children.

A Web-based store-and-forward teleconsultation asthma management system was implemented to provide subspecialty asthma care to military children with asthma living in the Western Pacific. Seven children with moderate to severe asthma (mean age 11.9 +/- 3.7 years) were followed for 1 year by their primary care provider (PCM) using a Web-based asthma pathway, with regular pediatric pulmonary teleconsults to Tripler Army Medical Center. Therapeutic monitoring included MPEG video recording of patient using metered-dose inhaler (MDI) technique submitted to the pulmonologist at specified intervals. Utilization of services for unscheduled asthma-related visits was monitored. PCMs were surveyed regarding their asthma practice before and after the intervention. Data were analyzed using Student's t test for continuous variables and Wilcoxon signed-rank or chi-square for noncontinuous variables. Therapeutic adherence was evidenced by improved inhaler technique in all patients. There were fewer ED visits for asthma (3.85 +/- 5.14, range 0-15 vs. 0 visits, p < 0.05) and fewer unscheduled acute clinic visits (1.57 +/- 1.27, range 0-4 vs. 0.286 +/- 0.48, p < 0.05) in the study year versus the preceding year. There were two hospitalizations in the year prior to the study; however, no patients were hospitalized during the study PCM use of an asthma action plan increased from 24% to 73% (p < 0.01) and provision of asthma education increased from 18% to 73%, (p < 0.01). However, PCMs reported that they were not more likely to watch their patient's MDI technique themselves (29% vs. 45%) nor order or interpret spirometry on their patients (12 vs. 18%). In this project, children with asthma followed by teleconsultation had improved outcomes. Store-and-forward teleconsultation can be used to follow children with chronic disease such as asthma over time.

The adherence and disease-control outcomes associated with the use of an Internet-based store-and-forward video home telehealth system to manage asthma in children were studied. Pediatric patients with persistent asthma were provided with home computers and Internet access and monitored biweekly over the Internet. All patients were seen in the pediatric clinic at 0, 2, 6, 12, and 24 weeks. Half of the patients received asthma education in person and half via an interactive Web site. Adherence measures were assessed by therapeutic and diagnostic monitoring. Therapeutic monitoring included digital videos of patients using their controller medication inhaler. Diagnostic monitoring included an asthma symptom diary and a video of peak flow meter use. Videos were submitted electronically twice a week by using in-home telemonitoring with store-and-forward technology. Feedback was provided electronically to each patient. Disease control was assessed by examining quality of life, utilization of services, rescue-therapy use, symptom control, satisfaction with home telemonitoring, and retention of asthma knowledge. Patients were randomly assigned to an asthma education group (Internet versus office), and the data were analyzed by comparing results for study days 0-90 and 91-180. Ten children participated. A total of 321 videos of inhaler use and 309 videos of peak flow meter use were submitted. Inhaler technique scores improved significantly in the second study period. Submission of diagnostic monitoring videos and asthma diary entries decreased significantly. Peak flow values as a percentage of personal best values increased significantly. Overall, there was no change in quality of life reported by patients. However, the caregivers in the virtual-education group reported an increase in the patients' quality-of-life survey scores. Emergency department visits and hospital admissions for asthma were avoided. Rescue therapy was infrequent. A high rate of satisfaction with home telemonitoring was reported. Internet-based, store-and-forward video assessment of children's use of asthma medications and monitoring tools in their homes appeared effective and well accepted.

More than a decade ago, bronchiectasis unrelated to cystic fibrosis was termed an "orphan disease", because it had become an uncommon clinical entity among children in the developed world. Bronchiectasis is more common among children in lower socioeconomic classes and in developing countries, presumably due to more frequent and recurrent respiratory infections, environmental airway irritants, poor immunization rates, and malnutrition. Reports from the Southern Pacific and from Alaska Native children reveal persistently high rates of childhood bronchiectasis. Better epidemiologic data throughout the world are needed to reassess the importance of this condition. The pathophysiology includes airway inflammation, mucus production, and regional airway obstruction, yet the reasons why some children develop bronchiectasis while other do not is unclear. The coexistence of asthma with bronchiectasis is associated with more severe disease, yet the impact of asthma therapy in children with both disorders has not been studied. Similarly, the pattern of antibiotic use for children with bronchiectasis varies by region with little data to justify one particular approach. It may be that public health measures aimed at improving living conditions for children and prevention of respiratory infections with antiviral vaccines will have more impact on childhood bronchiectasis than medical treatments in the future., (Copyright 2002 Wiley-Liss, Inc.)

A multidisciplinary program for managing asthma in a pediatric population is discussed. A coordinated, multidisciplinary program for managing asthma in children was initiated in November 1997 at a U.S. Army medical center. The program, designed to improve care and decrease hospitalizations for asthma, was pharmacist managed and pulmonologist directed and was implemented by pediatricians. Patient education was provided by a pediatric clinical pharmacist or a nurse case manager; providers also received intensive education. Follow-up occurred at predetermined intervals and included asthma education, discussion of expectations and goals, analysis of metered-dose-inhaler and spacer technique, and assessment of compliance. Between November 1997 and January 1999, 210 inpatients were screened for asthma. One hundred seven were believed to have asthma and received inpatient asthma counseling and teaching. Of these 107 patients, 79 were enrolled in the program and monitored in the ambulatory care setting. Seventy-one (90%) of the 79 program enrollees were not rehospitalized during the ensuing two years. The number of children admitted to the hospital for asthma decreased from 147 in 1997 (a rate of 3.2 per 1000 population) to 93 in 1998 (2.1 per 1000) and to 87 in 1999 (1.9 per 1000). A multidisciplinary approach to the management of children with asthma may reduce hospitalizations of such patients.

Pneumonia that is unresponsive to appropriate antibiotic therapy suggests an infection due to more unusual or resistant organisms. In this report, a child with unilateral pneumonia, pleural effusion, and anti-I cold hemagglutinin antibodies is presented. The usual causes of this clinical picture were suspected and treated, but the child did not improve. Features of her history suggested a more unusual etiology, and a diagnosis of leptospirosis was made. A brief discussion of leptospiral disease in children is provided.

Cough is an uncommon sign in infants. Cough may result from the presence of abnormal secretions in the airway or abnormalities of the central airways that affect the infant's ability to clear normal secretions. Tracheomalacia (TM) and gastroesophageal reflux (GER) can both cause cough in infants. Four infants whose cough began in the newborn period were diagnosed with TM and GER. Symptoms of central airway obstruction (homophonous wheeze or tracheal cough) suggested the diagnoses. In three patients, the diagnosis was made by barium esophagraphy and airway fluoroscopy. The infants responded to conservative and medical therapy for GER and to nebulized bronchodilators. Tracheomalacia and GER cause cough in infants that begins in the newborn period. The diagnosis can often be made with studies available to the primary care provider, and the conditions are often responsive to medical management.

Gastroesophageal reflux (GER) is being increasingly diagnosed and implicated for a range of pediatric problems. This study examines the diagnostic rate for GER in US Army hospitals between 1971 and 1995. During this 25-year period, 2059 diagnoses of GER were identified, for a 20-fold increase. Both the rate and total number of cases rose significantly in medical centers and community hospitals alike. The increase in GER diagnoses does not necessarily imply an increase in prevalence. It may be the result of an increased awareness of the problem or over diagnosis. However, it may also reflect an increased prevalence of pathologic GER, which is potentially the result of changes in the practice of infant care.

Objectives: To determine how frequently seating devices are available in homes with small infants and how often they are used for infants who are too young to sit erect and unsupported., Design: Observational study using a questionnaire administered to a cohort of parents of well infants younger than 5 months., Setting: Well-Baby Clinic, Department of Pediatrics, Tripler Army Medical Center, a tertiary care center serving the population of military dependents on the island of Oahu, Hawaii., Results: Infant seating devices were available in the homes of all of the infants whose parents completed the questionnaire during the study. Of 187 infants, 176 (94%) spent 30 minutes or longer in seating devices each day. The mean (tSD) time spent each day in seating devices was 5.7 +/- 3.5 hours and ranged from 0 to 16 hours., Conclusions: Seating devices were widely available for use in the care of the infants. Car seats that double as infant carriers and infant seats likely are being used extensively outside of automobiles. Prolonged use of infant seating devices with infants who are too young to sit unsupported may have several potential adverse consequences.

Background: Chronic cough is a common complaint encountered by physicians who care for children. It is also a common reason for referral to a pulmonologist. Determining the cause of chronic cough, however, rarely requires specialized diagnostic procedures that are unavailable to the primary care physician., Methods: A computerized listing of new patients referred to a pediatric pulmonologist between July 1993 and June 1995 was reviewed. Of 299 patients examined as outpatients during this period, 95 were referred for chronic cough. The diagnosis and diagnostic procedures were examined to determine how frequently procedures available exclusively to subspecialists were necessary to determine the cause of chronic cough., Results: Of the 95 patients who were examined for cough during the period studied, the diagnosis was made by history in 5, pulmonary function testing in 11, radiographic tests in 15, and a therapeutic trial in 58. In only 6 cases was the diagnosis made using tests unavailable to the primary care physician (5 bronchoscopy, 1 allergy skin testing)., Conclusions: In 89 cases the cause of chronic cough was determined by procedures available to the referring physician. In most cases chronic cough in children can be diagnosed and managed by physicians who are aware of the spectrum of common disorders that lead to cough.