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Objective: In 1995, the Children's Medical Services (CMS) of the State of Georgia contracted with the Department of Pediatrics of the Medical College of Georgia (MCG) and the MCG Telemedicine Center to develop telemedicine programs to provide subspecialty care for children with special health care needs. This article presents project statistics and results of client evaluation of services, as well as physician faculty attitudes toward telemedicine., Design: A demonstration project using telemedicine between a tertiary center and a rural clinic serving children with special health care needs was established. Data were collected and analyzed for December 12, 1995 to May 31, 1997, during which 333 CMS telemedicine consultations were performed., Results: Most CMS telemedicine consultations (35%) involved pediatric allergy/immunology. Other subspecialties included pulmonology (29%), neurology (19%), and genetics (16%). Overall, patients were satisfied with the services received. Initially, physician faculty members were generally positive but conservative in their attitudes toward using telemedicine for delivering clinical consultation. After a year's exposure and/or experience with telemedicine, 28% were more positive, 66% were the same, and only 4% were more negative about telemedicine. The more physicians used telemedicine, the more positive they were about it (r =.30)., Conclusions: In terms of family attitudes and individual care, telemedicine is an acceptable means of delivering specific pediatric subspecialty consultation services to children with special health care needs, living in rural areas distant to tertiary centers. Telemedicine is more likely to be successful as part of an integrated health services delivery than when it is the sole mode used for delivery of care.

Have you ever wondered if children coming into your dental operatory these days really are fatter, or is it just your imagination? And if they are fatter, how does it relate to what they are eating and what is the approach to treatment? This review article is written for dental health professionals, their own children, and their young patients and families, and will briefly address these issues.

The bilirubin-binding ability of neonatal serum was measured and compared with the serum bilirubin concentration and the serum bilirubin/albumin ratio. The bilirubin/albumin ratio correlated no better with the bilirubin-binding ability than the bilirubin concentration alone.

The aim of this project was to review the course of infants referred for consideration of extracorporeal membrane oxygenation (ECMO) to identify maximal ventilator settings that, when exceeded, did not provide clinical benefit to the patient. These settings might then be used in defining failure of conventional mechanical ventilation. We reviewed referral records and hospital charts of all infants treated for severe respiratory failure due to meconium aspiration syndrome during the 52.5 month period from March 15, 1985, to August 1, 1989. At an inspiratory pressure > 35 cm H2O, 75% (43/57) of patients eventually required ECMO, and 28% (4/14) of the infants who did not receive ECMO died. When the inspiratory pressure was > or = 40 cm H2O, 39/49 patients required ECMO, and 30% (3/10) of those not treated with ECMO died. Once the inspiratory pressure was > 45 cm H2O, 91% (29/32) of patients required ECMO, and only one third of those not treated with ECMO survived. Although the limitations for conventional therapy suggested in this paper may be helpful to clinicians, each center needs to establish guidelines for maximal conventional ventilator support. If these guidelines are clearly defined, alternative methods of therapy can be used once these criteria are achieved.

This study seeks to better describe the characteristics and outcomes of infants who stay for prolonged periods in the neonatal intensive care unit (NICU). Of 1174 consecutive admissions to a NICU, 73 (6%) met criteria for long-term neonatal intensive care (LTNIC). NICU care totaled 24,631 days; LTNIC infants needed 9152 days (37%). Average NICU stay for LTNIC infants was 125 days (SD +/- 102 days), compared with 14 days +/- 17 days for non-LTNIC infants. The LTNIC infants < or = 1500 gm accounted for 22% of the NICU days of care. There were no differences in gestational age, birth weight, gender, or race between LTNIC and non-LTNIC infants. Survival at discharge was not different, although when neonatal deaths (< or = 28 days) were excluded, the survival of LTNIC infants was significantly less (p < 0.0001). Of 56 LTNIC infants who survived to NICU discharge, 11 (three < or = 1500 gm) subsequently died before 2 years of age, and 10 (six < or = 1500 gm) were probably developmentally delayed. Infants with the longest NICU stays often have multiple medical and surgical problems and unfavorable outcomes, and they consume a disproportionately large percentage of NICU resources. Efforts to contain NICU costs, increase NICU bed availability, and improve NICU outcomes should not ignore infants who require prolonged NICU stays.

The relationship between nutrition and dentistry has been longstanding. Today, dental healthcare providers need to broaden the definition of "dental nutrition" from a narrow focus on the relationship of foods to caries, periodontal disease and oral lesions, to concerns about the overall nutritional adequacy of a patient's diet. This article discusses some of the latest nutrition recommendations put forth by major United States' health organizations and comments on their applicability to dental patients.

1. Parenteral amino acid solutions undergo photooxidation, which may be an important factor in total parenteral nutrition-associated hepatic dysfunction. Light-exposed parenteral solutions containing amino acids, in addition to vitamins and trace minerals, generate free radicals, which, in turn, may contribute to this type of injury. This study examined the characteristics of H2O2 production in a parenteral amino acid solution modelled on a commercially available paediatric parenteral amino acid solution. 2. The solution was exposed to light in the presence of riboflavin-5'-monophosphate (riboflavin), and peroxide formation in the presence and absence of catalase (H2O2 formation) was assayed using potassium iodide/molybdate. 3. Peak H2O2 production occurred at a light intensity of 8 microW cm-2 nm-1 in the 425-475 nm waveband and was linear to 2 h of light exposure. H2O2 production reached 500 mumol/l at 24 h. 4. H2O2 was directly related to a riboflavin concentration of up to 20 mumol/l and was maximal at 30 mumol/l. 5. H2O2 production was greatest in the amino acid/riboflavin solution at a pH of between 5 and 6. 6. Under the conditions of light exposure intensity, light exposure time, riboflavin concentration and pH found during the administration of parenteral nutrition in neonatal intensive care units, net H2O2 production occurs in solutions modelled on a paediatric parenteral amino acid preparation.

A viscoelastometer, the SonoClot Coagulation Analyzer, has been proposed for use in the evaluation of platelet function. The purpose of this study was to evaluate systematically this instrument when used with whole blood. Under laboratory conditions, the coefficient of variation (cv) of determinations of whole blood activated clotting time (ACT) on the instrument was approximately 7.0 percent. In contrast, the cv of measurements on whole blood related to the graphic events associated with clot formation ranged from 9.2 to 41.7 percent. Because of the large and variable cvs associated with these measurements of clotting, the SonoClot Analyzer cannot presently be recommended for use in studies designed to examine quantitatively the clotting function in whole blood.

The National Cholesterol Education Program (NCEP) has endorsed physician case finding as the primary method to detect individuals with elevated cholesterol levels. Despite this recommendation, promotional and for-profit public screening programs have flourished. We surveyed participants of a mall-based cholesterol screening program 1 year after their screening. Sixty-four percent of those screened had not previously known their cholesterol levels. Those who were newly screened were less likely to benefit from this testing than the general public, since they were older (mean age, 55.3 years), more likely to be female (67.4%), and nonsmokers (88%). Screenees had excellent recall of their cholesterol level (mean absolute reporting error, 0.24 mmol/L [9 mg/dL]) and a good understanding of cholesterol as a coronary heart disease risk. Those with elevated cholesterol levels reported high distress from screening but no reduction in overall psychosocial well-being and an actual decrease in absenteeism. Only 53.7% of all who were advised to seek follow-up because of an elevated screening value had done so within the year following the screening program. However, of those with values greater than 6.2 mmol/L (240 mg/dL), 68% had sought follow-up. Many of those who participate in public screening programs have been previously tested, fall into low-benefit groups, or fail to comply with recommended follow-up. We therefore conclude that cholesterol screening programs of the type now commonly offered are unlikely to contribute greatly to the national efforts to further reduce coronary heart disease.

Our short-term pilot study suggests that a dietitian can play an important role in the dental office. Patients, staff, and dentists perceived a need for nutrition counseling in the dental setting that is not presently being met. We suggest that a dietitian might effectively meet this need without putting a financial burden on the practice.

The need for exchange transfusion was analyzed retrospectively using several different methods (total bilirubin binding capacity, birth weight, plasma protein level, and two published charts). These predictive methods were applied to 175 jaundiced infants for whom all the data were available and to 19 infants who were actually exchanged. Most of the patients were sick, premature infants. This study demonstrates the lack of agreement among the predictive methods.

We examined the accuracy of laboratory screening tests in eight neonatal intensive care units. Analytes were provided by the EXCEL proficiency testing program of the College of American Pathologists (CAP), Skokie, III, samples were analyzed for hematocrit values and urine specific gravity. "Dipstick" tests were also performed for urinary protein, bilirubin, blood, glucose, pH, and ketones. The one intensive care unit that adhered to a formal quality control program for all these tests uniformly reported results well within statistically acceptable limits as defined by CAP. The seven other centers reported 14 instances of results that were either greater than 1 SD of the mean or considered by the consensus method to be outside acceptable CAP limits. Three of these results may have led to inappropriate clinical action in neonates. We conclude that there is a real potential for errors to be made in screening tests run by nurses in a neonatal intensive care unit when a formalized quality control program is not in effect.

This review article discusses some current questions concerning the measurement of bilirubin in the blood of newborn infants and the relationship of these blood parameters to the biochemical defects responsible for bilirubin encephalopathy. A discussion of numerous theories, which have been put forth to explain the specific biochemical mechanism by which bilirubin acts on brain metabolism, demonstrates that presently there is no unequivocal explanation for the molecular events leading to bilirubin encephalopathy.

The binding of dapsone, 4,4'-sulfonylbis(aniline)(1), and its diacetylated derivative, 4,4"'-sulfonylbis(acetanilide)(2), to human serum albumin is reported. To assess the ability of these compounds to displace 4'-[(4-aminophenyl)sulfonyl]acetanilide (3) from albumin, a dialysis rate technique was used. Competition for the bilirubin binding site on albumin was measured with the peroxidase assay. Compounds 1 and 2 strongly displaced both 3 and bilirubin from human serum albumin. The association constants for 1 and 2 with respect to bilirubin binding were 1.29 X 10(3) and 1.15 X 10(4) M-1, respectively. These results suggest that the binding site for 3 and the bilirubin binding site are similar with respect to 1 and 2 and that the binding of dapsone and its derivatives probably does not involve the amino function.

This study establishes levels of activity of glucose-6-phosphate dehydrogenase (G6PD), glycogen phosphorylase (GP), and cytochrome c oxidase (cyt c ox) in maternal, placental, and fetal tissues at Days 9, 12, and 15 in the 16-day gestation period of the hamster, and following a single dose of either 8 or 15 mg/kg mercuric acetate on the eighth gestational day. Mercury significantly elevated maternal kidney G6PD activity and decreased GP activity. The increase in kidney G6PD strongly correlated with observed urine and kidney abnormalities.

Glucose and acetaldehyde react covalently with albumin to form the post-translationally modified group of proteins, the glycosylated albumins and the acetaldehyde albumins, respectively. This study contrasts the binding ability of a major acetaldehyde albumin fraction synthesized in vitro with glycosylated albumin. A microdialysis rate method, using either [14C]monoacetyldiaminodiphenyl sulfone (MADDS), a deputy ligand for bilirubin, or [14C]diazepam, was employed to evaluate binding at these two sites. Our results indicate that prolonged exposure of purified human serum albumin to acetaldehyde results in a major acetaldehyde albumin fraction that lacks the ability to bind MADDS and diazepam. This fraction migrates identically to albumin on SDS polyacrylamide gel electrophoresis, but exhibits microheterogeneity with a more acidic pI band as seen on analytical isoelectric focusing. We suggest that altered drug binding in alcoholics may be partially explained by altered binding ability of acetaldehyde albumins.

Total plasma bilirubin, apparent unbound plasma bilirubin, cerebellar glycogen and Purkinje cells were quantified in heterozygous Gunn rats, homozygous Gunn rats and normal Wistar rats. Our results indicated that, in the Gunn rat, total bilirubin, apparent unbound bilirubin, and the bilirubin/albumin molar ratio are highly correlated with each other and with alterations in cerebellar Purkinje cells and accumulation of cerebellar glycogen. In addition, cerebella of heterozygous Gunn rats contained many abnormal Purkinje cells without intramitochondrial glycogen and cerebella of homozygous Gunn rats showed many Purkinje cells with intramitochondrial glycogen. Our results demonstrate previously unreported differences between heterozygous Gunn rats and controls. We suggest that population of Purkinje cells in the heterozygous Gunn rats may have received a cellular insult from fetal exposure to bilirubin.

We examined the relationship of plasma unbound bilirubin concentration and reserve albumin-binding concentration for bilirubin in a sample of 545 neonates. Plasma unbound bilirubin concentration and total bilirubin-binding concentration were determined with the peroxidase assay. Contrary to published reports, we found that plasma unbound bilirubin concentration and plasma reserve albumin for bilirubin-binding concentration are highly correlated (r = -0.706; p less than 0.001) and that the relationship between these two parameters is dependent upon the total bilirubin-binding concentration. That these measured parameters correlate in the same manner as predicted for free bilirubin and free albumin by the law of mass action, suggests that these measurements may be meaningful.

It is difficult to maintain an objective attitude toward the use of vitamin E in neonatology. On the one hand, the desire to ameliorate iatrogenic diseases, such as BPD and ROP, makes one grasp hopefully at any theory or clinical trial that suggests a role for vitamin E in decreasing the handicaps that patients take with them from the intensive care nursery. On the other hand, when the question of toxicity arises, one tends to be negative, remembering the unfortunate experiences with oxygen, chloramphenicol, sulfisoxazole, and now, E-Ferol Aqueous Solution. We like to think that if this review had been written 2 years ago, our conclusions, based on the analysis of the data, would have been the same. But, probably, in the absence of data on the severe toxicity of one vitamin E preparation, we would have been more liberal in our recommendations for the use of vitamin E in neonatology. At this time, however, any use of supplemental vitamin E beyond the guidelines of the American Academy of Pediatrics cannot be recommended. Nor can the monitoring of blood Vitamin E levels be recommended as an assurance of nontoxic tissue concentrations in sick, premature infants. All physicians caring for premature infants are urged to review their nursery policies to make sure that excessive doses of vitamin E are not being administered. It is hoped that additional clinical trials will provide more definite answers to the questions about the efficacy of vitamin E in ROP and IVH.

Drugs known to affect the red blood cell membrane and used clinically in neonates were tested for their ability to cause increased 14C-bilirubin uptake by erythrocyte ghosts. The additional uptake of bilirubin by ghosts in the presence of penicillin G, phenobarbital, furosemide and theophylline may be explained by the effect of these drugs on free bilirubin levels as measured with a horseradish peroxidase assay. In contrast, the effect of chlorpromazine in causing increased bilirubin uptake by ghosts could not be totally explained by either ghost lysis or increased free bilirubin levels, as measured by light scattering, and was due to a direct effect of chlorpromazine on the ghost membrane. Our results demonstrate that drugs may act through different mechanisms in causing increased bilirubin uptake by erythrocytes.