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Pneumocystis carinii pneumonia
18 2
Letters to the Editor
Academy of Pediatrics. In 1966, the concerns of these practitioners centered on mental health aspects of pediatric hospital care. On their behalf, the Mental Health Committee conducted a survey of 6 general hospitals with pediatric services, a where 90 per cent of children receive their inpatient care. Program-centered administrative consultation, a technique described by Caplan, 4 was applied effectively by a pediatrician. The study has initiated immediate, longrange, and ongoing effects in the hospitals visited. Publication of this study has served to assist other pediatricians and psychiatrists in improving this area of care in their own hospitals. As a next step, the Mental Health Committee has further explored the needs of local pediatricians in dealing with behavioral and emotional health problems in private practice. In the August, 1969, semiannual newsletter of the Northern California Chapter of the American Academy of Pediatrics, the membership was asked to respond by postcard checklist on how its Mental Health Committee could best serve its needs. 5 Eighty (20 per cent) of the members completed the questionnaire; their answers indicated that at least this many pediatricians wanted help in interview technique, knowing where to refer patients, and in detection and prevention of emotional problems. The respondents expressed interest in attending seminars, group discussions, and talks and wanted to receive audio- and videotapes and newsletters on these subjects. Results of this survey were reported in the next semiannual newsletter. In January, 1970, an open meeting of the Mental Health Committee was held with advance notification of all membership, so that it was well attended by interested pediatricians. The meeting identified current postgraduate educational efforts in IocaI communities of northern California. These included involvement of child psychiatrists in individual case-centered consultation, group meetings for case-centered consultation, regularly scheduled seminars discussing emotional growth and development, interview skills, diagnostic approaches to specific age groups, and joint efforts to improve pediatric services in general hospitals. Thus gradually the concerns and interests of pediatric practitioners are coming to be recognized, and postgraduate programs are being devised to meet their requirements. In addition, pediatricians have combined with other health professionals in planning, presenting, and attending rnultidiscipline meetings de-
The Journal o[ Pediatrics January 1971
voted to aspects of behavioral pediatrics. In San Francisco alone, the following meetings are being held this year: (1) The American Association for Child Care in Hospital, fifth annual meeting, April, 1970, under the leadership of Dr. Helen Glaser, offering 16 seminars on different aspects of care of the hospitalized child, (2) The San Francisco Psychoanalytic Institute, symposium on the Effects of Hospitalization on Children, September, 1970, with panels by local and national authorities in pediatrics and psychiatry, (3) The American Academy of Pediatrics, thirty-ninth annual meeting, October, 1970, where its Child Development Section will be devoted to "behavioral pediatrics," including the hospitalized child. With these local and national trends, the teaching of "behavioral pediatrics" should begin to serve the practitioner as well offer stimulus for concurrent clinical research.
Helene S. Thorpe, M.D., M.P.H. University of Cali[ornia School of Medicine Davis, Call[. REFERENCES
1. Friedman, S. B.: The challenge in behavioral pediatrics, J. PEDIA'r. 77: 172, 1970. 2. Thorpe, H. S., and Halpern, W. I.: Pediatricians and a community child guidance clinic. II. Mental health aspects in pediatric practices, Pediatrics 36: 777, 1965. 3. Thorpe, H. S., and Rousseau, P.: Hospital facilities for children: The pediatrician as a consultant in mental health aspects of hospital care, Amer. J. Dis. Child. 177: 558, 1969. 4. Caplan, G.: Principles of preventive psychiatry, New York, 1964, Basic Books, Inc., p. 212. 5. Newsletter of the California Chapter I, District IX, American Academy of Pediatrics, articles from 1966 through 1970.
Pneumocystis carinii pneumonia To the Editor: In our recent article on the subject of Pneumocystis carinii pneumonia in siblings (J. PED~T. 76: 769, 1970), we failed to credit the article entitled "Pneumocystis carinii pneumonia in siblings: Diagnosis by lung aspiration," by D. M. O. Becroft and J. M. Costello, from the Princess Mary Hospital for Children in Auckland (New Zeal. Med. J. 64: 273, 1965). Their initial patient was a 5 ~ month infant who had hypogammaglobulinemia and died with
Volume 78 Number 1
pneumonia of unknown etiology. Pneumocystis carinii pneumonia was considered premortem, and an attempt to confirm the diagnosis was made by examination of hypopharyngeal secretions. No organisms were detected. The diagnosis was confirmed at autopsy. At the age of 6 months a brother, born 10 months after the death of his sibling, developed pneumonia. This patient also suffered from hypogammaglobulinemia and from recurrent infections. Pneumocystis earinii was suspected as the etiologic agent, and the diagnosis was made by examination of material obtained from a lung aspirate. Treatment with pentamidine was begun but the infant died. We apologize for overlooking this excellent article.
Letters to the Editor
18 3
The promised "feeling of accomplishment and satisfaction" is a legitimate objective only insofar as the physician actually accomplishes and satisfies.
]ulius Landwirth, M.D. Yale-New Haven Hospital 789 Howard Ave. New Haven, Conn. 06504
Reply To the Editor: I thank Dr. Landwirth for his interest in the article "The management of the irate parent." I certainly agree with the points that he makes and hope that he, myself, and others carry work in this area to greater depth.
Jack S. Remington, M.D. Layne O. Gentry, M.D. Palo Alto Medical Research Foundation 860 Bryant St. Palo Alto, Calif.
Jerome L. Schulman, M.D. The Children's Memorial Hospital 2300 Children's Plaza Chicago, Ill. 60614
Management o/the irate parent To the Editor: In his article "The management of the irate parent" (J. PEO~T. 77: 338, 1970), Dr. Schulman deals with a sorely neglected problem. Most pediatricians have experienced not only the personal exasperation but, much more importantly, the ways in which so-called "difficult parents" can subtly influence their effectiveness in the care of the sick child. There is a need for detailed study of the interplay of various stages of disease states and the environmental circumstances in which they are managed in order to provide a more encompassing definition of a given child's problem and optimal therapy. We may then learn how better to identify and anticipate potentially provocative situations in a manner which relates directly to the ultimate test, namely, its effect on the patient's condition. To treat the subject in broad generalities, as Dr. Schulman does, tends to emphasize the glib techniques for manipulation of parental feelings designed to bring them back into line with our established medical regimens. It understates the priority of learning to confront and deal with specific substantive issues and measuring the results of their modification by the rule of therapeutic efficacy.
Achilles reflex time in thyroid disorders To the Editor: In their recent study, Costin and associatesx came to the conclusion that the Achilles reflex time is of little diagnostic value with respect to thyroid disorders in children. Although careful statistical evaluation has been carried out in their study and the results are in complete agreement with our own experience, we cannot agree with the conclusions which, in our opinion, underestimate the diagnostic value of the Achilles reflex time. It is uncontested that several nonthyroid factors may alter the reflex time considerably. Our results with respect to the modifying effect of insulin and glucose,2 as well as of physical exercise and adrenaline, 3 are identical with those reported by the authors. However, the poor correlation between the reflex time and other tests of thyroid function reported in their paper is in our opinion predominantly due to the application of inadequate normal values and does not mean that the reflex time is of no use in the diagnosis
Letters to the Editor
Academy of Pediatrics. In 1966, the concerns of these practitioners centered on mental health aspects of pediatric hospital care. On their behalf, the Mental Health Committee conducted a survey of 6 general hospitals with pediatric services, a where 90 per cent of children receive their inpatient care. Program-centered administrative consultation, a technique described by Caplan, 4 was applied effectively by a pediatrician. The study has initiated immediate, longrange, and ongoing effects in the hospitals visited. Publication of this study has served to assist other pediatricians and psychiatrists in improving this area of care in their own hospitals. As a next step, the Mental Health Committee has further explored the needs of local pediatricians in dealing with behavioral and emotional health problems in private practice. In the August, 1969, semiannual newsletter of the Northern California Chapter of the American Academy of Pediatrics, the membership was asked to respond by postcard checklist on how its Mental Health Committee could best serve its needs. 5 Eighty (20 per cent) of the members completed the questionnaire; their answers indicated that at least this many pediatricians wanted help in interview technique, knowing where to refer patients, and in detection and prevention of emotional problems. The respondents expressed interest in attending seminars, group discussions, and talks and wanted to receive audio- and videotapes and newsletters on these subjects. Results of this survey were reported in the next semiannual newsletter. In January, 1970, an open meeting of the Mental Health Committee was held with advance notification of all membership, so that it was well attended by interested pediatricians. The meeting identified current postgraduate educational efforts in IocaI communities of northern California. These included involvement of child psychiatrists in individual case-centered consultation, group meetings for case-centered consultation, regularly scheduled seminars discussing emotional growth and development, interview skills, diagnostic approaches to specific age groups, and joint efforts to improve pediatric services in general hospitals. Thus gradually the concerns and interests of pediatric practitioners are coming to be recognized, and postgraduate programs are being devised to meet their requirements. In addition, pediatricians have combined with other health professionals in planning, presenting, and attending rnultidiscipline meetings de-
The Journal o[ Pediatrics January 1971
voted to aspects of behavioral pediatrics. In San Francisco alone, the following meetings are being held this year: (1) The American Association for Child Care in Hospital, fifth annual meeting, April, 1970, under the leadership of Dr. Helen Glaser, offering 16 seminars on different aspects of care of the hospitalized child, (2) The San Francisco Psychoanalytic Institute, symposium on the Effects of Hospitalization on Children, September, 1970, with panels by local and national authorities in pediatrics and psychiatry, (3) The American Academy of Pediatrics, thirty-ninth annual meeting, October, 1970, where its Child Development Section will be devoted to "behavioral pediatrics," including the hospitalized child. With these local and national trends, the teaching of "behavioral pediatrics" should begin to serve the practitioner as well offer stimulus for concurrent clinical research.
Helene S. Thorpe, M.D., M.P.H. University of Cali[ornia School of Medicine Davis, Call[. REFERENCES
1. Friedman, S. B.: The challenge in behavioral pediatrics, J. PEDIA'r. 77: 172, 1970. 2. Thorpe, H. S., and Halpern, W. I.: Pediatricians and a community child guidance clinic. II. Mental health aspects in pediatric practices, Pediatrics 36: 777, 1965. 3. Thorpe, H. S., and Rousseau, P.: Hospital facilities for children: The pediatrician as a consultant in mental health aspects of hospital care, Amer. J. Dis. Child. 177: 558, 1969. 4. Caplan, G.: Principles of preventive psychiatry, New York, 1964, Basic Books, Inc., p. 212. 5. Newsletter of the California Chapter I, District IX, American Academy of Pediatrics, articles from 1966 through 1970.
Pneumocystis carinii pneumonia To the Editor: In our recent article on the subject of Pneumocystis carinii pneumonia in siblings (J. PED~T. 76: 769, 1970), we failed to credit the article entitled "Pneumocystis carinii pneumonia in siblings: Diagnosis by lung aspiration," by D. M. O. Becroft and J. M. Costello, from the Princess Mary Hospital for Children in Auckland (New Zeal. Med. J. 64: 273, 1965). Their initial patient was a 5 ~ month infant who had hypogammaglobulinemia and died with
Volume 78 Number 1
pneumonia of unknown etiology. Pneumocystis carinii pneumonia was considered premortem, and an attempt to confirm the diagnosis was made by examination of hypopharyngeal secretions. No organisms were detected. The diagnosis was confirmed at autopsy. At the age of 6 months a brother, born 10 months after the death of his sibling, developed pneumonia. This patient also suffered from hypogammaglobulinemia and from recurrent infections. Pneumocystis earinii was suspected as the etiologic agent, and the diagnosis was made by examination of material obtained from a lung aspirate. Treatment with pentamidine was begun but the infant died. We apologize for overlooking this excellent article.
Letters to the Editor
18 3
The promised "feeling of accomplishment and satisfaction" is a legitimate objective only insofar as the physician actually accomplishes and satisfies.
]ulius Landwirth, M.D. Yale-New Haven Hospital 789 Howard Ave. New Haven, Conn. 06504
Reply To the Editor: I thank Dr. Landwirth for his interest in the article "The management of the irate parent." I certainly agree with the points that he makes and hope that he, myself, and others carry work in this area to greater depth.
Jack S. Remington, M.D. Layne O. Gentry, M.D. Palo Alto Medical Research Foundation 860 Bryant St. Palo Alto, Calif.
Jerome L. Schulman, M.D. The Children's Memorial Hospital 2300 Children's Plaza Chicago, Ill. 60614
Management o/the irate parent To the Editor: In his article "The management of the irate parent" (J. PEO~T. 77: 338, 1970), Dr. Schulman deals with a sorely neglected problem. Most pediatricians have experienced not only the personal exasperation but, much more importantly, the ways in which so-called "difficult parents" can subtly influence their effectiveness in the care of the sick child. There is a need for detailed study of the interplay of various stages of disease states and the environmental circumstances in which they are managed in order to provide a more encompassing definition of a given child's problem and optimal therapy. We may then learn how better to identify and anticipate potentially provocative situations in a manner which relates directly to the ultimate test, namely, its effect on the patient's condition. To treat the subject in broad generalities, as Dr. Schulman does, tends to emphasize the glib techniques for manipulation of parental feelings designed to bring them back into line with our established medical regimens. It understates the priority of learning to confront and deal with specific substantive issues and measuring the results of their modification by the rule of therapeutic efficacy.
Achilles reflex time in thyroid disorders To the Editor: In their recent study, Costin and associatesx came to the conclusion that the Achilles reflex time is of little diagnostic value with respect to thyroid disorders in children. Although careful statistical evaluation has been carried out in their study and the results are in complete agreement with our own experience, we cannot agree with the conclusions which, in our opinion, underestimate the diagnostic value of the Achilles reflex time. It is uncontested that several nonthyroid factors may alter the reflex time considerably. Our results with respect to the modifying effect of insulin and glucose,2 as well as of physical exercise and adrenaline, 3 are identical with those reported by the authors. However, the poor correlation between the reflex time and other tests of thyroid function reported in their paper is in our opinion predominantly due to the application of inadequate normal values and does not mean that the reflex time is of no use in the diagnosis