Neonatologist attrition to general pediatrics.
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Adult↗
Biomedical subjects
M Jellinek
Publications and source records attributed to M Jellinek.
Supporting child psychiatric services using current managed care approaches: you can't get there from here.
For-profit behavioral health care companies have transformed the way mental health services are provided for children. Using marketplace approaches, companies have "carved out" mental health services for many patients receiving care from pediatricians. This report details specific approaches used by these firms to maximize profits, minimize the role of child and adolescent psychiatrists, and limit clinical services. Understanding for-profit carveouts will help primary care pediatricians appreciate the likely consequences of such reimbursement incentives for the care of children and their families.
Adolescent↗
Pediatric psychosocial screening: of sufficient benefit to encourage.
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Child↗
The Pediatric Symptom Checklist. Support for a role in a managed care environment.
OBJECTIVES: To gather data based on studies of the Pediatric Symptom Checklist, identify risk factors associated with high levels of dysfunction in primary care pediatric settings, and explore the relationship between common risk factors and psychosocial problems identified by pediatricians. DESIGN: Retrospective review and cross-sectional, case-referent survey. SETTING: Subjects were selected from three primary care pediatric clinics in Massachusetts: a private practice in a predominantly white, middle-class suburb, an urban health maintenance organization clinic, and an inner-city clinic. PARTICIPANTS: Of 423 outpatients aged 6 to 12 years screened for psychosocial problems, 72 children and their families were seen for in-depth structured and clinical interviews (24 from each site). INTERVENTIONS: None. MEASUREMENTS/MAIN RESULTS: Children with a single parent and/or those who were economically disadvantaged were significantly more likely to show psychosocial impairment. The specificity of the Pediatric Symptom Checklist was 100% in samples with a lower socioeconomic status compared with 68% in middle-class samples, and sensitivity was 95% in middle-class samples compared with 80% in lower-class samples. Pediatricians identified psychosocial problems in eight of 15 children with a history of familial mental illness or substance abuse and seven of eight children with a history of physical or sexual abuse, but only six of 17 cases from single-parent families and four of 11 cases from poor families. CONCLUSIONS: Pediatricians should be sensitive to psychosocial dysfunction especially in single-parent and low-income families. Use of the Pediatric Symptom Checklist for psychosocial screening in a managed health care delivery system could target capitated resources efficiently by providing early identification and secondary prevention of psychosocial morbidity.
Affective Symptoms↗
MEGX (monoethylglycinexylidide): a novel in vivo test to measure early hepatic dysfunction after hypovolemic shock.
A quantitative liver test based on the formation of the lidocaine metabolite monoethylglycinexylidide (MEGX), was used to evaluate the effect of hemorrhagic shock at 40 mmHg for 90 min on Sprague-Dawley rats. After 2 h of stabilization, lidocaine was injected (2 mg/kg). A second group received volume resuscitation with Ringer's lactate over 1 h (15 mL/kg) after shock, and after 1 h of stabilization lidocaine was administered. These groups were compared to control animals. Blood samples were drawn at 0 time (baseline), prior to lidocaine injection, and at 10, 15, 30, and 60 min after lidocaine injection. MEGX values in shocked animals were significantly lower than in the control group; in animals receiving volume resuscitation, levels were higher than the shocked animals without resuscitation, but did not reach control levels. Thus, shock produced a significant depression of hepatocyte function, which was partially reversed by Ringer's lactate resuscitation. The MEGX test appears to be a suitable tool for clinical evaluation and therapeutic intervention after shock.
Animals↗
Clinical correlates of enuresis in ADHD and non-ADHD children.
Enuresis and attention deficit hyperactivity disorder (ADHD) are common childhood disorders that often co-occur. Although each has been linked to neurodevelopmental immaturity and increased risk for psychopathology, the clinical correlates of enuresis remain unclear. Subjects were 140 6-17-year-old boys with DSM-III-R ADHD and 120 non-ADHD controls. Information on enuresis and psychiatric diagnoses was obtained in a standardized manner blind to the child's clinical status. Our results show that (1) enuresis did not increase the risk for psychopathology in children with or without ADHD; (2) enuresis was not associated with psychosocial adversity or developmental immaturity; (3) enuresis was associated with increased risk for learning disability, impaired intellectual functioning, and impaired school achievement in normal control children but not in children with ADHD; and (4) the same pattern of findings was obtained after stratifying children with enuresis by primary versus secondary and by nocturnal versus diurnal subtypes. These results suggest that the clinical implications of enuresis may differ for ADHD and non-ADHD children.
Adolescent↗
The effect of shock on blood oxidation-reduction potential.
Oxidation-reduction (redox) potential measurements were made in the blood of rabbits subjected to hemorrhagic shock followed by treatment with a mild oxidizing agent (albumin). Control redox potential reading corrected for pH was -8.8 +/- 1.3 millivolts (mV) in arterial blood (A) and -18.0 +/- 2.0 mV in venous blood (V). This A-V difference indicated that hydrogen equivalents coming from muscle and other tissues were partially consumed in the lungs. A 20-mV drop on the V and a 13 mV on the A side was seen after shock. This did not fully return to control 2 h after return of the shed blood. Infusion of 2 g of albumin/kg/h raised the V redox potential to control, but it returned to untreated levels when the albumin was discontinued. The reductive load imposed on the animal by shock appeared to be large and not readily reversed by reperfusion or by the quantity of albumin given. Thus, it may be concluded that cellular respiration had not been adequately restored. This reductive load may impede recovery by suppression of cellular respiration and other cell and organ functions.
Animals↗
Pyrimidine-enhanced purine uptake in hepatocytes and improved survival from hypovolemic shock.
To assess the effect of pyrimidines on the incorporation of purines into rat hepatocytes, monolayer preparations of hepatocytes were incubated with radiolabeled precursors and their uptake determined. The uptake of purine precursors (inosine monophosphate, inosine, and hypoxanthine) was 27.8 +/- 1.31 nmoles per well, per 30 min. In the presence of added pyrimidines (uridine monophosphate, uridine, and orotate), this increased by 22%. Further enhancement (45%) was observed when L-dihydroxyphenylalanine (L-DOPA) plus pyridoxal-5'-phosphate was added to the purine/pyrimidine incubation medium. The effect of increased uptake of purines on survival after hypovolemic shock was also studied. Rats were bled to a blood pressure of 40 mmHg for 105 min and then treated with return of shed blood plus saline with or without purines and pyrimidines. Survival at 24 hr was 43% (15/35) in control animals, 66% (8/12) (P = 0.276) when treated with inosine monophosphate (IMP) and aspartate (60 mumoles/kg each), and 83% (10/12) (P = 0.037) for IMP with aspartate and orotate treatment (60 mumoles/kg each). Thus, the addition of orotate enhanced survival possibly by promoting salvage or by uptake of purines. Nucleotide concentrations in the livers of animals after shock which had received IMP and orotate demonstrated a return of both ATP and energy charge to normal, further indicating the value of this treatment.
Adenosine Diphosphate↗
Clearance and maintenance of blood nucleotide levels with adenosine triphosphate-magnesium chloride injection.
ATP-MgCl2 has been found to be helpful in experimental animals after shock and ischemia with improvement in organ function and survival. The reasons for this pharmacologic action are unclear. To evaluate the clearance and circulation of ATP and its metabolites after intravenous injection, 20 rabbits received ATP-MgCl2 as a bolus injection or a continuous intravenous infusion. Arterial blood was withdrawn, and ATP and its metabolites were measured using a high-performance liquid chromatography (HPLC) technique with ultraviolet (UV) absorption. Forty seconds following a bolus injection, only 1% of the injected dose was present in arterial blood as ATP, and at 280 sec only inosine remained. With a 60 min continuous ATP-MgCl2 infusion, the inosine level peaked at 62.9% at 30 min and was 37.6% at 60 min, whereas ATP was 4.9% and AMP was 17.4% at 60 min. Thus a single dose of ATP-MgCl2 has a half-life of less than 40 sec as ATP. With a continuous infusion, although some ATP circulates, inosine and AMP are the major remaining nucleotides. Thus, the beneficial effects of ATP-MgCl2 may be through ATP itself with magnesium or with adenine nucleotide metabolites for recycling of the nucleotides, phosphorylation of cell membrane inositides, and/or its vasoactive effects.
Adenosine Diphosphate↗
Diagnosed intellectual and emotional impairment among parents who seriously mistreat their children: prevalence, type, and outcome in a court sample.
A substantial body of research evidence over the past three decades has indicated that intellectual and emotional impairment among parents is a factor contributing to child abuse and neglect. This study examined the court records of 206 seriously abused or neglected children and their families in a large urban area and found that in over half the records a parent had been diagnosed as having an emotional disorder and/or low IQ, with a majority of these diagnoses indicating significant impairment. Although type of impairment (emotional, low IQ, and a subsample of substance abusers) did not predict type of mistreatment, higher predicted risk for continued mistreatment, or greater likelihood of permanent removal of the child by the court, low IQ parents revealed significantly less prior court involvement and greater acceptance of court-ordered services. Parents diagnosed with serious emotional disorders were significantly more likely than less disturbed parents to have their children permanently removed despite findings of no significant differences in risk or compliance factors.
Affective Symptoms↗
Substance abuse and serious child mistreatment: prevalence, risk, and outcome in a court sample.
This study examined the prevalence and specific types of substance abuse in a sample of 206 cases of serious child abuse or neglect brought before a metropolitan juvenile court on care and protection petitions. In 43% of the cases, at least one of the parents had a documented problem with either alcohol or drugs, a figure which rose to 50% when alleged instances of substance abuse were included. Alcohol, cocaine, and heroin were the three most frequently mentioned abused substances. Parents with documented substance abuse were significantly more likely than nonsubstance-abusing parents to have been referred previously to child protective agencies, to be rated by court investigators as presenting high risk to their children, to reject court-ordered services, and to have their children permanently removed. When the two factors of court investigator high risk ratings and presence of parental substance abuse were combined, it was possible to obtain even higher levels of prediction of which parents would reject services and have their children permanently removed. Results suggest (1) the importance of increased screening, evaluation, and treatment of parental substance abuse in cases of serious child mistreatment; and (2) the possibility of adopting a predictive approach as to which families will be able to respond to court-ordered treatment requests and have their children returned.
Alcoholism↗
The Pediatric Symptom Checklist: validation in the real world of middle school.
Examined the validity of the Pediatric Symptom Checklist (PSC), a brief parent-completed psychosocial screening questionnaire, in a sample of 166 students from a public middle school. Positive screening on the parent PSC was significantly associated with independent ratings by the students' guidance counselor and teachers of the need for regular counseling; any academic failure during the next 2 years; and PSCs competed by the students about themselves. Most students who screened positive on the parent PSC were found to have significant problems in at least one of the above areas. The PSC also identified a group of students whose difficulties were previously unknown to school personnel. For pediatric psychologists, guidance counselors, and pediatricians who need to identify middle-school students with serious psychosocial problems, the PSC appears to be a valid and useful first-stage screening instrument.
Achievement↗
Effect of liquid diet on nude mouse gastrointestinal tract.
The nude (athymic) mouse is currently used to study the effect of gastrin on cancer xenografts. We sought to develop a hypogastrinemia nude mouse model for use in evaluating the effect of hypogastrinemia on such xenografts. Thirty-six non-tumor-bearing nude mice were studied. Eighteen received a nutritionally complete liquid diet; eighteen received standard chow. Six mice from each group were weighed and killed (nonfasting) on days 2, 8, and 15. Mean serum gastrin levels (+/- SEM) for the control group were 118.7 +/- 7.5, 118.7 +/- 8.7, and 118.0 +/- 7.5 pg/ml on days 2, 8, and 15, respectively. Serum gastrin levels for the liquid diet group significantly decreased to 87.0 +/- 7.6, 88.0 +/- 9.7, and 66.7 +/- 9.6 pg/ml on the same days. Animals in both groups gained weight normally; there were no significant weight differences between the two groups at any point. No histological abnormalities were seen in stomach, small intestine, colon, cecum, liver, pancreas, spleen or kidney. However, the liquid diet group showed atrophic changes in colon: significant reductions in colon weight and RNA content on days 8 and 15, and significant reduction in colon protein content on day 8. This model of hypogastrinemia is reliable and inexpensive. The nonsurgical nature of the preparation allows excellent survival in this immunodeficient animal.
Animals↗
Oxidation-reduction maintenance in organ preservation.
The isolated perfused organ is more sensitive to the toxicity of oxygen since hypothermia reduces the activities of enzymes responsible for minimizing oxygen toxicity. To protect the organ under these conditions reducing agents must be added to the perfusate. Quantitation of the resulting reduction is best obtained by measurement of the oxidation-reduction potential of the perfusate. A device was designed for this purpose and, by electrochemical principle, controlled reduction of the oxidized form of the oxidation-reduction couple was affected. Kidneys were perfused with cryoprecipitated plasma. With the electrochemical cell in the circuit, the oxidation-reduction potential of the perfusate was adjusted by the addition of ascorbic acid and glutathione and the cell was driven by a battery-powered potentiostat. Kidneys subjected to 60 minutes of warm ischemia had optimal survival at -20 mV. Preservation for six days in a monitored group had no survivors, whereas kidneys with oxidation-reduction support maintained life. Optimal oxidation-reduction support maintained life. Optimal oxidation-reduction was at or near -17 mV. These data show a requirement of an optimal oxidation-reduction potential to reverse warm ischemia damage and to prolong the period of ex vivo preservation of isolated perfused organ.
Animals↗
An experimental evaluation of nucleotide enhancement techniques for kidney transplantation.
The effect of various nucleotide-enhancing agents on renal function and intracellular nucleotide levels was evaluated in a canine autotransplant model. Thirty-five dogs (18-28 kg) underwent left nephrectomy and 30 min of warm ischemia followed by Collins C-4 flush and 24 hr of cold-storage preservation. Heterotopic autotransplantation and immediate contralateral nephrectomy was then performed. Seven equal groups were evaluated: group A--controls, group B--adenosine pretreatment (1.0 g), group C--dipyridamole pretreatment (10 mg), group D--adenosine (1.0 g), and dipyridamole (10 mg) pretreatment, group E--adenosine (200 mg) and EHNA (2.5 mg/kg) pretreatment, group F--adenosine (200 mg) and EHNA (2.5 mg/kg) in the Collins C-4 flush, and group G--adenosine (200 mg) and EHNA (2.5 mg/kg) at the time of autotransplantation. All kidneys underwent cortical biopsies at the end of preservation and 1 hr after restoration of blood flow for determinations of AMP, ADP, and ATP. In the pretreatment groups (groups B through E) there was 60% graft survival whereas the controls (group A) and the groups treated after ischemia (groups F and G) had 0, 0, and 20% graft survival, respectively. In groups B and E, ATP levels were greater than controls after preservation and 1 hr after restoration of blood flow. Group C AMP and ADP levels and group D energy charge were greater than controls in the post-transplantation biopsies. Administration of adenosine and EHNA after ischemia was not associated with increased intracellular nucleotide levels. One hour post-transplantation biopsies demonstrated greater ability to regenerate cortical nucleotides in the surviving animals but no absolute value could be identified as a predictor of viability. In conclusion, pretreatment with adenosine, dipyridamole, and EHNA alone and in combination is beneficial in ischemically injured kidneys undergoing cold-storage preservation.
Adenine↗
The effect of dietary manipulation on hepatic lipid accumulation in rats undergoing small intestinal bypass.
Small intestinal bypass performed for morbid obesity produces hepatic fat infiltration which persists in some patients for more than 5 years. In an attempt to define causative and preventative factors of hepatic steatosis following small intestinal bypass, a rat model was developed. In this study, nutritionally obese rats underwent sham operations or bypass of 90 per cent of their small intestine and postoperatively were fed various diets to determine the effects of dietary manipulations on hepatic lipid content. After 30 days the rats were killed and their hepatic lipid content and lipogenic enzyme activity determined. In rats that underwent intestinal bypass neither a high fat, a high carbohydrate nor a high protein diet increased hepatic lipid content over that present in sham operated animals. A low (4.5 per cent) protein diet increased total hepatic lipid and hepatic triglyceride content. The increased triglyceride levels were not associated with significant changes in lipogenic enzyme activity and were associated with decreased serum triglycerides suggesting impaired triglyceride transport from the liver secondary to decreased lipoprotein formation as a possible etiologic mechanism. A significant inverse relationship was found between hepatic triglyceride content and hepatic protein content. These results support previous reports from human studies of hypoproteinemia associated with hepatic steatosis following small intestinal bypass.
Acetyl-CoA Carboxylase↗
Improved myocardial preservation by control of the oxidation-reduction potential.
Simple cold storage remains the current method of preservation of human heart allografts between removal and transplantation, but this technique is not adequate for prolonged periods of preservation. An alternative to cold storage is machine perfusion of the isolated organ. Although this technique has yielded promising results in kidney preservation, there is limited experience with the heart. One factor limiting the effectiveness of perfusion preservation is the toxicity of oxygen free radicals generated during the perfusion. The generation and reduction of these radicals results in an electron transfer, producing an electrochemical potential known as the redox potential. This study examines the role of machine perfusion in heart preservation with and without the use of a new electrochemical cell that is able to control the redox potential during the perfusion. Hearts were preserved for twenty-four hours by either simple cold storage (Group I), or by machine perfusion with redox monitoring (Group II), or redox control (Group III). Control of the oxidation-reduction potential of the perfusate during machine perfusion of isolated hearts resulted in significantly improved systolic and diastolic function after perfusion compared to hearts that underwent machine perfusion without redox control or simple cold storage.
Animals↗
Improved function of perfused rabbit kidneys by prevention of oxidative injury.
This study explored the effect of adding small amounts of the reducing agents ascorbic acid and glutathione to a Ringer's-albumin perfusate used for 24-hr hypothermic perfusion of rabbit kidneys. Maintenance of function during preservation was evaluated with a shunt perfusion model and by measuring the ability of cortical slices to restore normal K/Na ratios after incubation in a electrolyte medium. When placed in contact with the unmodified perfusate, an electrode of pyrolytic carbon registered a potential of +190 mV relative to the silver-silver chloride couple. This reading fell rapidly by 100-125 mv when kidneys were placed on the circuit. The mean creatinine clearance after 24-hr perfusion was significantly improved from 162 +/- 56 ml/hr in controls to 284 +/- 92 ml/hr when the potential indicated by this electrode was preadjusted to 43-54 mv with reducing agents, and to 237 +/- 62 ml/hr when this adjustment was made after 2 hr. These creatinine clearances were similar to those of kidneys stored on ice for only 1 hr. These findings indicate minimal injury occurred in the chemically reduced groups and emphasize the importance of preventing oxidative damage to kidneys during hypothermic organ perfusion. The time course of the changes in potential registered by this electrode was consistent with our previous finding that much of the damage to perfused kidneys occurs very early in the course of perfusion. The tissue slice studies showed no detectable damage to the renal parenchyma of the kidneys in the control group despite diminished creatinine clearance. This suggests that the site of oxidation injury is the vascular compartment.
Animals↗