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Clinical facts and curios
Clinical Facts and Curios 1.
Q. You are a painter, a janitor, a printer, or perhaps a forestry worker. What is the chance that your offspring will have a congenital birth defect?
A. A Canadian
population-based registry examined 14,415 live-born children with birth defects between the years 1952 and 1973. The father’s occupation was obtained from the birth certificate in order to determine a potential relationship between his occupation and the type of birth defects observed. The results revealed a set of remarkable findings. Paternal occupations found to be associated with an increased odds ratio (OR) or birth defects include: Painters
Janitors
Spina bifida (OR = 3.21) Patent ductus arteriosus (OR = 2.34) Cleft palate (OR = 3.36)
Hydrocephalus (OR = 5.04) Ventricular septal defects (OR = 2.45) Other heart defects (OR = 2.35) Forestry Workers
and Logging Printers
Congenital cataract (OR = 2.28) Atria1 septal defects (OR = 2.03) Svndactvlv (OR = 2.03) Plywood
Atresia of the urethra (OR = 4.50) Clubfoot (OR = 2.18)
Mill Workers
Patent ductus arteriosus (OR = 2.52) Pyloric stenosis (OR = 4.12) Dislocated hip (OR = 2.71)
This study obviously has several limitations and the results must be viewed with some caution. Nonetheless, where there is smoke there is fire and the further role of a father’s occupation in the etiology of birth defects should be examined. (Olshan AF, et al: Am J Ind Med 1991, 20:447.) 2.
Q. How good is the lactational
amenorrhea
method
A. The LAM is the informed use of breast-feeding
(LAM) as a contraceptive?
as a contraceptive method by a woman who is still amenorrheic up to 6 months after delivery. To be effective, the baby should not be taking other sources of nutrition. Under these conditions, LAM users are thought to have a 98% rate of protection from pregnancy. Cumulative probabilities of ovulation during lactational amenorrhea are 30.9 and 67.3 per 100 women at 6 and 12 months, respectively. Cumulative pregnancy rates during lactational amenorrhea are 2.9 and 5.9 per 100 women at 6 and 12 months, compared with 0.7 at 6 months for LAM (Kennedy KI, et al: Lancet 1992; X$9:227). To say all this differently, It a woman IS ~111wrtnout penoas and is not supplementing breast-feeding, she has relatively little need for contraceptives. Instead of going on the pill, go on the LAM-it works.
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1992
Clinical Facts and Curios
3.
Q. If you are a sun worshipper, galls tones?
do you have a higher chance
of developing
A. Yep. In one study, among 206 white-skinned
individuals, a positive attitude toward sun bathing was associated with twice the risk of cholelithiasis in comparison to those who shunned sun bathing (relative risk = 2.1) (Pave1 S, et al: Lanacet 1992; 339:291). In fact, if you restrict the findings of this report to people who always burn after prolonged sun bathing (skin type I), the relative risk of developing gallstones skyrockets to a relative risk of 25.6. Could suntan lotions prevent gallstones?
4.
Q. Do individuals who were treated with radium years ago for otitis media have an increased risk of malignancy?
A. This query is not about a topic that is as obscure as it seems. Thousands of U.S. military personnel have been treated with radium applicators. Beginning in World War II, the Navy recognized aerotitis media as a problem for trainees practicing underwater escapes in the submarine service. Otic barotrauma was reported in 26.9% of trainees at the submarine training facility near New London, Connecticut. Radium treatment of the nasopharyngeal orifice at each eustachian tube in these trainees was said to reduce the rate of recurrence of symptomatic aerotitis media from 100% to less than 20% (Haines HL, et al: Ann Otol Rhino/ Laryngol 1946; 55327). The average radiation dose was 2,000 rads. Available records indicate that radium treatment for middle-ear disease continued through 1968 in the military, suggesting that at least 5,000 individuals were so treated in Connecticut alone. So what does all this mean with respect to children? We don’t know except that some children have been similarly treated. Radium implants have been used to reduce hearing loss associated with various middle-ear infections. Among 904 children who had received such treatment between 1943 and 1960, 4 died of malignant head and neck tumors by 1980 (3 of brain cancer and 1 of soft-palate cancer). No such tumors have been detected in untreated subjects in a control group (Sandler DP, et al: J Nat/ Cancer Inst 1982; 68:3). We will need to be very watchful when it comes to this little known problem. 5.
Q. How much does a second of cigarette advertising
cost?
A. In 1988, U.S. manufacturers
spent $3.27 billion on cigarette advertising and promotion, the equivalent of $100 per second, not of advertising time, but real time. Eleven percent of the dollars, or $355 million, was spent on magazine advertising, making cigarettes the second most heavily advertised product in this medium. A fascinating observation was recently made by Warner and colleagues (Warner KE, et al: N Engl J Med 1992; 326:305) who found that the probability of finding any article on the risks of smoking in any given year was reduced by approximately 40% for magazines with advertising revenues derived from cigarette advertisements. Either tobacco smoke is clouding the judgment of the editors of some of our best magazines, or tobacco manufacturers are picking their outlets very carefully.
Current Problems in Pediatrics / November/December
1992
453
Clinical Facts and Curios
6.
Q. What is the average cholesterol
level of a Zen monk?
A. The answer to this question proves how dramatically
diet can influence our blood cholesterol levels. Zen monks eat a daily diet containing just 3 mg of cholesterol. The average cholesterol level of a Zen monk is 136 mg/dL! Before going on a Zen diet, recognize, however, that being monastical involves sitting around a lot, which is likely to lower your high-density-lipoprotein (HDL) cholesterol, the good cholesterol. In fact, this is exactly what was shown in the monks, a low total cholesterol level but a low HDL cholesterol as well. (Otani H, et al: N Engl J Med 1992; 396:416.)
7.
Q. Who is likely to have the highest blood pressure and who is likely to have the lowest blood pressure: a child with no, one, two, or three siblings?
A. The more the merrier. There is a continuous inverse correlation between the number of siblings and the mean blood pressure. are seen among children with no siblings. Those have statistically lower blood pressures. (Wincup 325:891.) If you are a one-child family, rent a kid. Better 8.
The highest blood pressures with three or more siblings P, et al: N Engl J Med 1992; still, rent a couple of kids.
Q. You are caring for a child who recently developed a malignant What is the latest in terms of detection of metastatic disease?
melanoma.
A. If you said polymerase chain reaction (PCR), you would have been correct. The PCR can be used to detect cancer cells in the peripheral blood by amplifying specific DNA sequences of tumor cell by-products. In the case of malignant melanoma, one can detect the presence of active tyrosine transcription using PCR. The most minuscule amounts of DNA can be detected in the circulation. Investigators in London have shown that a single malignant cell in 2 mL of blood can readily by found (Smith B, et al: Lancet 1991; 338:1227). Blood samples from 4 to 7 patients with malignant melanoma gave positive PCR results, whereas results for 8 control subjects were negative. Several research laboratories are hot on the trail of utilizing PCR for a wide range of malignancies. If the technique proves applicable, it will revolutionize our ability to determine which patient has active metastatic disease and which does not. 9.
Q. There is a “dark” side of running. What is it?
A. It is when exercise becomes an addiction. De Coverley Veale (Br J Addict 1987; 82:735) proposed formal criteria for diagnosing exercise dependence. An individual who is exercise dependent is a person who has a rigid exercise pattern, training once or twice daily; who gives increasing priority to exercise so that it begins to supersede other activities; who shows increasing tolerance to the exercise activity (must exercise more to gain the same perceived benefits); who has withdrawal symptoms affecting mood after stopping exercise; who can find relief of withdrawal symptoms only by exercising; and who rapidly returns to the compulsive exercise behavior after a period of inactivity. The pendulum has finally begun to swing away from those who have any legitimate basis for thinking exercise is ,good. I can visualize it now: A scene from an upcoming play in which a man emerges from a silent group to timidly proclaim, “My name is Alex. I am an addicted runner.” (After which there is an
454
Current
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1992
Clinical Facts and Curios
embarrassing silence followed ner’s Anonymous.)
10.
by polite applause
from other members
of Run-
Q. At this time every 4 years, things become presidential. What is the link between endocrinology and the ability to achieve the highest elected office in this country?
A. The link is height. In previous “Clinical Facts and Curios,” the height advantage of presidential candidates was noted. Prior to this year’s election, the taller candidate was elected in 18 of the last 22 presidential campaigns. This, of course, began with George Washington. Boller (Boller PF: The Presidents. Oxford University Press, 1984) reported that just prior to taking the oath of office, George Washington asked advice at a dinner party about titles under consideration for the first leader of the country. Suggestions included His Excellency, Elective Majesty, His Serene Highness, and His Elective Highness. At 6 ft 2 in., Washington favored “His Mightiness” but ultimately settled for “Mr. President.” Mr. Perot, we thank you for an interesting candidacy, even though most of it was undeclared. Clearly, you have been on the “short” list of those running.
11.
Q. Continuing on the theme of stature, can you arrange the following Presidents and presidential aspirants in sequential order according to height: George Washington, James Madison, Abraham Lincoln, Gerald R. Ford, Jimmy Carter, Ronald Reagan, George Bush, Bill Clinton, Ross Perot?
A. James Madison had the least available genetic material to achieve significant stature. He was 5 ft 4 in. tall, the shortest president ever. Ross Perot follows on the list at 5 ft 6 in. Then comes Jimmy Carter at 5 ft 9 l/4 in. Gerald R. Ford made it to 6 ft until he lost some of his hair. Ronald Reagan is next in line at 6 ft 1 in. George Washington and George Bush have equal stature at 6 ft 2 in. but are surpassed by Bill Clinton at 6 ft 2% in. The tallest president, of course, was Old Abe. He towered over most everybody at 6 ft 4 in. He could even look down on Lyndon B. Johnson (6 ft 3 in.). Yes, the politics of height are complex and highly capable of being influenced by recombinant growth hormone. 12.
Q. Which of the following activities is the safest for teenagers: wrestling, horseback riding, playing football, participating in track and field, or intercollegiate basketball?
A. Of all these, the equestrian one is the safest. From highest to lowest risk for injury, the order is wrestling (10.7/l ,000 exposures), football playing (6.1/l ,000 exposures), track and field participation (5.68/1,000 hours of exposure), intercollegiate basketball playing (4.5/l ,000 person-hours of exposure), and lastly, riding a horse (approximately l/l ,000 lessons, rides, or riding hours). Please do not think that riding a horse is entirely safe. The above-mentioned statistics were generated by Nelson and colleagues (Nelson DE, et al: Am J Dis Child 1992; 146:611) who also showed that despite the low risk, horseback injuries are quite serious. Approximately 2,300 persons younger than 25 years are hospitalized annually because of equestrian injuries. Substantively more girls than boys seek medical attention because of horseback injuries. Injuries to the head, many of them serious, are the major cause of hospitalization. How to prevent equestrian injuries is still an issue for further investigation. The only national equestrian organization that requires protective headgear for
Current
Problems
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1992
455
Clinical Facts and Curios
all equestrian activities is the U.S. Pony Club. Both the American Academy of Pediatrics and the American Medical Association, however, have endorsed the use of protective headgear for equestrian activity. Although no studies to date have demonstrated the effectiveness of helmets for horseback riders, based on data from bicyclists and motorcylists, it seems only common sense to think that a hard-shell helmet could greatly reduce head injury. Horses are nice critters, but they can hurt. Although falls are the most common mechanism of injury in adolescents who ride horses, kicks, bites, crushing injuries, trampling, being dragged along the ground with a foot trapped in a stirrup, and collisions with fixed objects also maim and injure. Children and young adults should be very alert and careful when on or near horses. 13.
Q. You are asked by the mother of a child with well-controlled seizures whether her daughter can participate in recreational horseback riding. What do you advise her?
A. Current recommendations
are that well-controlled epilepsy as well as insulindependent diabetes are not considered indications for restriction of horseback riding (Brooks WH, et al: Physician Sports Med 1988; 16:84). There are, however, five generally accepted contraindications to recreational equestrian sports: history of cervical fracture or dislocation, congenital absence of the ondontoid process of the axis, temporary paralysis from any cause, head injury with permanent impairment, and congenital narrowing of the spinal canal.
14.
Q. What is gram-negative and motile, possesses a single flagellum, grows on charcoal-E yeast extract agar but not on MacConkey agar, and is susceptible to ceftriaxone, amikacin, gentamicin, and cefotaxime? A clue is that it was recently given a new name, Afipia felis.
A. If “felis” didn’t give it away, you must be slipping. Afipia felis is the name for the organism that causes cat-scratch disease (Brenner DG, et al: J C/in Microbiol 1991; 29:2450). The best kept pearl is the origin of the genus portion of the new name for this infective agent. It is derived from the abbreviation AFIP, for the Armed Forces Institute of Pathology where the organism was isolated.
15.
Q. You are responsible for quality assurance for the pediatric department of your small local hospital. The head of nursing for the newborn intensive care unit (ICU) is setting up a human milk supply system for some of the babies. As is done in other institutions, fresh human milk is frozen for storage. The question, however, is whether or not it is okay to use a microwave oven to thaw the frozen human milk?
A. This is quite a good question. Microwave
ovens have become a commonplace tool in the workplace. It would, in fact, seem reasonable to thaw frozen human milk using this rapid method. lhdeed, Goldblum and colleagues (Goldblum RM, et al: J Pediatr 1984; 104:380) showed that rapid, high-temperature treatment does not destroy the immunologic qualities of human milk. No change in the concentration of lactoferrin, secretory IgA, and serum IgA antibody activity was seen following rapid heat treatment for brief periods (15 seconds at 70” C). Note, however, that Quan and associates (Quan R, et al: Pediatrics 1992; 89:667) showed that microwaving at higher temperatures (72”-98” C) causes a marked decrease in the activity of all anti-infective factors of human milk. At tem-
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1992
Clinical Facts and Curios
peratures of 20” to 25” C Escherichia co/i will grow five times faster in microwaved human milk than in slowly thawed, frozen human milk. Why microwaving causes this problem is hard to understand, The adverse effects on anti-infective factors cannot be on the basis of hyperthermia alone, since the temperatures used are not excessive. It is possible that microwaving may produce some nonthermal effects on human milk. To make a long story shorter, tell the head of the neonatal ICU to take the microwave oven home where it belongs. 16.
Q. The same director of nursing in the previous question rings you up again. The query is whether a recent switch to cloth diapers should result in any different routine management of infants in the neonatal /CU. How would you respond? A. You would have to look up an article in a recent issue of the Journal of Perinatology (Hermansen MC, et al: J Perinatol 1992; 12:72). If you switch from disposable diapers to cloth ones, you may run into a problem with inaccurate determinations of urine output, if you are using the diaper-weighing method for the purpose of quantifying urine output. Evaporation from reusable cloth diapers exposed to radiant heat is 51% at 1 hour and 82% after 2 hours, compared to almost nothing from super-absorbent diapers. Thus, you may be misled into thinking that with cloth diapers, the urinary output is diminished. A prior “Clinical Facts and Curios” described a phenomenon of superabsorbent diaper pseudoanuria (when a super-absorbent diaper feels dry to the touch even though an infant has recently urinated). Well, now we see that there is a cloth diaper pseudoanuria, since cloth diapers allow the urine to evaporate, misleading us into thinking that infants have urinated less than what they really have.
17.
Q. The next two questions have to do with the upper and lower parts of this world. The first is, what is lime disease in the Antarctic?
A. Recently described
was the case of a member of the personnel of the US. Antarctic Research Base at Amundsen-Scott Station, South Pole. This was a fellow who complained of severe pain in his right elbow. A diagnosis of acute lateral epicondylitis was made. It seems that this was traumatically induced by excessive lime squeezing. Lime squeezing is a common activity at the South Pole. Apparently, fresh limes delivered in bulk by air are stored in a “heated” refrigerator in an outside environment. A heated refrigerator is used since the average ambient temperature is -76” C and you actually have to warm the environment to 5” C to keep the limes fresh. However, because of the extremely low water content of the ambient air at the South Pole and the degree of heating required to maintain a constant temperature of 5” C, the relative humidity plummets, resulting in dessicated limes. For this reason, lime-squeezing parties are common at the South Pole in order to produce lime juice that can then be frozen for later use. Thus, the origin of lime disease in the Antarctic (Souseal MP: N Engl J Med 1992; 326:351).
18.
Q. The second frigid question is from a real-life drama. How would you deal with the following dilemma? One night in March of last year, 30 miles north of the Arctic Circle, a 5-yearold Eskimo boy was out for the evening with his father, attending the Eskimo dance performance at a local high school. The temperature was 35” F below
Current
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1992
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Clinical Facts and Curios
zero. While walking home in the middle of virtually nowhere, the child stopped and licked a handrail and was instantly frozen to the railing by his tongue and upperlip. His father attempted to free him but could not. Instead, he resorted to a novel, effective, a/though somewhat curious means of freeing the boy. What did he do that you yourself could do as well?
A. This is not truly a fair question since presumably only about half of you could easily use the approach the father took. He urinated on the boy’s tongue, quickly freeing him (Adler Al, et al: N Engl J Med 1992; 326:351).
STATEMENT OF OWNERSHIP, MANAGEMENT AND CIRCULATION (Required by 39 U.S.C. 3685). 1. Title of Publication: CURRENT PROBLEMS IN PEDIATRICS. 1A. Publication number: 00459380. 2. Date of filing: October 1, 1992. 3. Frequrncy of issue: Monthly except for June and December. 3A. No. of issues published annually: 10. 3B. Annual subscription price: $65.00. 4. Location of known office of publication: Mosby-Year Book, Inc., 200 North La.%& Street, Chicago, Illinois 60601-1080. 5. Location of the headquarters or general business offices of the publishers: Mosby-Year Book, Inc., 11830 Westline Industrial Drive, St. Louis, Missouri 63146.3318. 6. Names and complete addresses of publisher, editor, and managing editor: Publisher-Frank N. Paparello, Mosby-Year Book, Inc., 545 Great Road, Littleton, Massachusetts 01460; EditorNorman C. Fost, MD, Dept. of Pediatrics, Room H4/452. University of Wisconsin Hospital, 600 Highland Avenue, Madison, WI 53792-4108; Managing Editor-Richard J. Wallace, Mosby-Year Book, Inc., 545 Great Road, Littleton, Massachusetts 01460. 7. Owner: Mosby-Year Book, Inc., a corporation, owner of publication, 11830 Westline Industrial Drive, St. Louis, Missouri 63146-3318. All of the stock of Mosby-Year Book, Inc. is owned by Times Mirror Company, a corporation, Times Mirror Square, Los Angeles, California 90053. 8. Known bondholders, mortgagees, and other security holders owning or holding lepercent or more of total amount of bonds, mortgages or-other securities: None. 9. Not applicable to Mosby-Year Book, Inc.
A. Total no. copies printed (net press run) B. Paid circulation 1. Sales through dealers and carriers, street vendors and counter sales 2. Mail subscriptions C. Total paid circulation 1). Free distribution by mail, carrier or other means, samples. complimentary, and other free copies , E. Total distribution (Sum OfCZ and II) F. Copies not distributed 1. Office USC, left over, unaccounted, spoiled after printing 2. Returns from news agents G. Total(Sum ofE, Fl and 24hmdd equalnetpress run shown in A) 1 I. I cernfv that the statements
made by me above are correct
12. In accordance with the provisions of this statue, I hereby postage rates presently authorixd by 39 USC. 3626.
2,829
2,983
None 2,358 2,358 117
NO”C 2,298 2,298 86
2,475
2,384
354 NO”C 2,829
599 NO”C 2,983
and complete. reques; permission
CAROI. TKUMROLD. Vice President and Journal Publicher to mail the publication named in Item 1 at the phased CAROI. TRUMROI.L). Vice President and Journal
458
Current Problems
in Pediatrics
/ November/December
1992
Publisher
Q. You are a painter, a janitor, a printer, or perhaps a forestry worker. What is the chance that your offspring will have a congenital birth defect?
A. A Canadian
population-based registry examined 14,415 live-born children with birth defects between the years 1952 and 1973. The father’s occupation was obtained from the birth certificate in order to determine a potential relationship between his occupation and the type of birth defects observed. The results revealed a set of remarkable findings. Paternal occupations found to be associated with an increased odds ratio (OR) or birth defects include: Painters
Janitors
Spina bifida (OR = 3.21) Patent ductus arteriosus (OR = 2.34) Cleft palate (OR = 3.36)
Hydrocephalus (OR = 5.04) Ventricular septal defects (OR = 2.45) Other heart defects (OR = 2.35) Forestry Workers
and Logging Printers
Congenital cataract (OR = 2.28) Atria1 septal defects (OR = 2.03) Svndactvlv (OR = 2.03) Plywood
Atresia of the urethra (OR = 4.50) Clubfoot (OR = 2.18)
Mill Workers
Patent ductus arteriosus (OR = 2.52) Pyloric stenosis (OR = 4.12) Dislocated hip (OR = 2.71)
This study obviously has several limitations and the results must be viewed with some caution. Nonetheless, where there is smoke there is fire and the further role of a father’s occupation in the etiology of birth defects should be examined. (Olshan AF, et al: Am J Ind Med 1991, 20:447.) 2.
Q. How good is the lactational
amenorrhea
method
A. The LAM is the informed use of breast-feeding
(LAM) as a contraceptive?
as a contraceptive method by a woman who is still amenorrheic up to 6 months after delivery. To be effective, the baby should not be taking other sources of nutrition. Under these conditions, LAM users are thought to have a 98% rate of protection from pregnancy. Cumulative probabilities of ovulation during lactational amenorrhea are 30.9 and 67.3 per 100 women at 6 and 12 months, respectively. Cumulative pregnancy rates during lactational amenorrhea are 2.9 and 5.9 per 100 women at 6 and 12 months, compared with 0.7 at 6 months for LAM (Kennedy KI, et al: Lancet 1992; X$9:227). To say all this differently, It a woman IS ~111wrtnout penoas and is not supplementing breast-feeding, she has relatively little need for contraceptives. Instead of going on the pill, go on the LAM-it works.
452
Current
Problems
in Pediatrics
/ November/December
1992
Clinical Facts and Curios
3.
Q. If you are a sun worshipper, galls tones?
do you have a higher chance
of developing
A. Yep. In one study, among 206 white-skinned
individuals, a positive attitude toward sun bathing was associated with twice the risk of cholelithiasis in comparison to those who shunned sun bathing (relative risk = 2.1) (Pave1 S, et al: Lanacet 1992; 339:291). In fact, if you restrict the findings of this report to people who always burn after prolonged sun bathing (skin type I), the relative risk of developing gallstones skyrockets to a relative risk of 25.6. Could suntan lotions prevent gallstones?
4.
Q. Do individuals who were treated with radium years ago for otitis media have an increased risk of malignancy?
A. This query is not about a topic that is as obscure as it seems. Thousands of U.S. military personnel have been treated with radium applicators. Beginning in World War II, the Navy recognized aerotitis media as a problem for trainees practicing underwater escapes in the submarine service. Otic barotrauma was reported in 26.9% of trainees at the submarine training facility near New London, Connecticut. Radium treatment of the nasopharyngeal orifice at each eustachian tube in these trainees was said to reduce the rate of recurrence of symptomatic aerotitis media from 100% to less than 20% (Haines HL, et al: Ann Otol Rhino/ Laryngol 1946; 55327). The average radiation dose was 2,000 rads. Available records indicate that radium treatment for middle-ear disease continued through 1968 in the military, suggesting that at least 5,000 individuals were so treated in Connecticut alone. So what does all this mean with respect to children? We don’t know except that some children have been similarly treated. Radium implants have been used to reduce hearing loss associated with various middle-ear infections. Among 904 children who had received such treatment between 1943 and 1960, 4 died of malignant head and neck tumors by 1980 (3 of brain cancer and 1 of soft-palate cancer). No such tumors have been detected in untreated subjects in a control group (Sandler DP, et al: J Nat/ Cancer Inst 1982; 68:3). We will need to be very watchful when it comes to this little known problem. 5.
Q. How much does a second of cigarette advertising
cost?
A. In 1988, U.S. manufacturers
spent $3.27 billion on cigarette advertising and promotion, the equivalent of $100 per second, not of advertising time, but real time. Eleven percent of the dollars, or $355 million, was spent on magazine advertising, making cigarettes the second most heavily advertised product in this medium. A fascinating observation was recently made by Warner and colleagues (Warner KE, et al: N Engl J Med 1992; 326:305) who found that the probability of finding any article on the risks of smoking in any given year was reduced by approximately 40% for magazines with advertising revenues derived from cigarette advertisements. Either tobacco smoke is clouding the judgment of the editors of some of our best magazines, or tobacco manufacturers are picking their outlets very carefully.
Current Problems in Pediatrics / November/December
1992
453
Clinical Facts and Curios
6.
Q. What is the average cholesterol
level of a Zen monk?
A. The answer to this question proves how dramatically
diet can influence our blood cholesterol levels. Zen monks eat a daily diet containing just 3 mg of cholesterol. The average cholesterol level of a Zen monk is 136 mg/dL! Before going on a Zen diet, recognize, however, that being monastical involves sitting around a lot, which is likely to lower your high-density-lipoprotein (HDL) cholesterol, the good cholesterol. In fact, this is exactly what was shown in the monks, a low total cholesterol level but a low HDL cholesterol as well. (Otani H, et al: N Engl J Med 1992; 396:416.)
7.
Q. Who is likely to have the highest blood pressure and who is likely to have the lowest blood pressure: a child with no, one, two, or three siblings?
A. The more the merrier. There is a continuous inverse correlation between the number of siblings and the mean blood pressure. are seen among children with no siblings. Those have statistically lower blood pressures. (Wincup 325:891.) If you are a one-child family, rent a kid. Better 8.
The highest blood pressures with three or more siblings P, et al: N Engl J Med 1992; still, rent a couple of kids.
Q. You are caring for a child who recently developed a malignant What is the latest in terms of detection of metastatic disease?
melanoma.
A. If you said polymerase chain reaction (PCR), you would have been correct. The PCR can be used to detect cancer cells in the peripheral blood by amplifying specific DNA sequences of tumor cell by-products. In the case of malignant melanoma, one can detect the presence of active tyrosine transcription using PCR. The most minuscule amounts of DNA can be detected in the circulation. Investigators in London have shown that a single malignant cell in 2 mL of blood can readily by found (Smith B, et al: Lancet 1991; 338:1227). Blood samples from 4 to 7 patients with malignant melanoma gave positive PCR results, whereas results for 8 control subjects were negative. Several research laboratories are hot on the trail of utilizing PCR for a wide range of malignancies. If the technique proves applicable, it will revolutionize our ability to determine which patient has active metastatic disease and which does not. 9.
Q. There is a “dark” side of running. What is it?
A. It is when exercise becomes an addiction. De Coverley Veale (Br J Addict 1987; 82:735) proposed formal criteria for diagnosing exercise dependence. An individual who is exercise dependent is a person who has a rigid exercise pattern, training once or twice daily; who gives increasing priority to exercise so that it begins to supersede other activities; who shows increasing tolerance to the exercise activity (must exercise more to gain the same perceived benefits); who has withdrawal symptoms affecting mood after stopping exercise; who can find relief of withdrawal symptoms only by exercising; and who rapidly returns to the compulsive exercise behavior after a period of inactivity. The pendulum has finally begun to swing away from those who have any legitimate basis for thinking exercise is ,good. I can visualize it now: A scene from an upcoming play in which a man emerges from a silent group to timidly proclaim, “My name is Alex. I am an addicted runner.” (After which there is an
454
Current
Problems
in Pediatrics
/ November/December
1992
Clinical Facts and Curios
embarrassing silence followed ner’s Anonymous.)
10.
by polite applause
from other members
of Run-
Q. At this time every 4 years, things become presidential. What is the link between endocrinology and the ability to achieve the highest elected office in this country?
A. The link is height. In previous “Clinical Facts and Curios,” the height advantage of presidential candidates was noted. Prior to this year’s election, the taller candidate was elected in 18 of the last 22 presidential campaigns. This, of course, began with George Washington. Boller (Boller PF: The Presidents. Oxford University Press, 1984) reported that just prior to taking the oath of office, George Washington asked advice at a dinner party about titles under consideration for the first leader of the country. Suggestions included His Excellency, Elective Majesty, His Serene Highness, and His Elective Highness. At 6 ft 2 in., Washington favored “His Mightiness” but ultimately settled for “Mr. President.” Mr. Perot, we thank you for an interesting candidacy, even though most of it was undeclared. Clearly, you have been on the “short” list of those running.
11.
Q. Continuing on the theme of stature, can you arrange the following Presidents and presidential aspirants in sequential order according to height: George Washington, James Madison, Abraham Lincoln, Gerald R. Ford, Jimmy Carter, Ronald Reagan, George Bush, Bill Clinton, Ross Perot?
A. James Madison had the least available genetic material to achieve significant stature. He was 5 ft 4 in. tall, the shortest president ever. Ross Perot follows on the list at 5 ft 6 in. Then comes Jimmy Carter at 5 ft 9 l/4 in. Gerald R. Ford made it to 6 ft until he lost some of his hair. Ronald Reagan is next in line at 6 ft 1 in. George Washington and George Bush have equal stature at 6 ft 2 in. but are surpassed by Bill Clinton at 6 ft 2% in. The tallest president, of course, was Old Abe. He towered over most everybody at 6 ft 4 in. He could even look down on Lyndon B. Johnson (6 ft 3 in.). Yes, the politics of height are complex and highly capable of being influenced by recombinant growth hormone. 12.
Q. Which of the following activities is the safest for teenagers: wrestling, horseback riding, playing football, participating in track and field, or intercollegiate basketball?
A. Of all these, the equestrian one is the safest. From highest to lowest risk for injury, the order is wrestling (10.7/l ,000 exposures), football playing (6.1/l ,000 exposures), track and field participation (5.68/1,000 hours of exposure), intercollegiate basketball playing (4.5/l ,000 person-hours of exposure), and lastly, riding a horse (approximately l/l ,000 lessons, rides, or riding hours). Please do not think that riding a horse is entirely safe. The above-mentioned statistics were generated by Nelson and colleagues (Nelson DE, et al: Am J Dis Child 1992; 146:611) who also showed that despite the low risk, horseback injuries are quite serious. Approximately 2,300 persons younger than 25 years are hospitalized annually because of equestrian injuries. Substantively more girls than boys seek medical attention because of horseback injuries. Injuries to the head, many of them serious, are the major cause of hospitalization. How to prevent equestrian injuries is still an issue for further investigation. The only national equestrian organization that requires protective headgear for
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all equestrian activities is the U.S. Pony Club. Both the American Academy of Pediatrics and the American Medical Association, however, have endorsed the use of protective headgear for equestrian activity. Although no studies to date have demonstrated the effectiveness of helmets for horseback riders, based on data from bicyclists and motorcylists, it seems only common sense to think that a hard-shell helmet could greatly reduce head injury. Horses are nice critters, but they can hurt. Although falls are the most common mechanism of injury in adolescents who ride horses, kicks, bites, crushing injuries, trampling, being dragged along the ground with a foot trapped in a stirrup, and collisions with fixed objects also maim and injure. Children and young adults should be very alert and careful when on or near horses. 13.
Q. You are asked by the mother of a child with well-controlled seizures whether her daughter can participate in recreational horseback riding. What do you advise her?
A. Current recommendations
are that well-controlled epilepsy as well as insulindependent diabetes are not considered indications for restriction of horseback riding (Brooks WH, et al: Physician Sports Med 1988; 16:84). There are, however, five generally accepted contraindications to recreational equestrian sports: history of cervical fracture or dislocation, congenital absence of the ondontoid process of the axis, temporary paralysis from any cause, head injury with permanent impairment, and congenital narrowing of the spinal canal.
14.
Q. What is gram-negative and motile, possesses a single flagellum, grows on charcoal-E yeast extract agar but not on MacConkey agar, and is susceptible to ceftriaxone, amikacin, gentamicin, and cefotaxime? A clue is that it was recently given a new name, Afipia felis.
A. If “felis” didn’t give it away, you must be slipping. Afipia felis is the name for the organism that causes cat-scratch disease (Brenner DG, et al: J C/in Microbiol 1991; 29:2450). The best kept pearl is the origin of the genus portion of the new name for this infective agent. It is derived from the abbreviation AFIP, for the Armed Forces Institute of Pathology where the organism was isolated.
15.
Q. You are responsible for quality assurance for the pediatric department of your small local hospital. The head of nursing for the newborn intensive care unit (ICU) is setting up a human milk supply system for some of the babies. As is done in other institutions, fresh human milk is frozen for storage. The question, however, is whether or not it is okay to use a microwave oven to thaw the frozen human milk?
A. This is quite a good question. Microwave
ovens have become a commonplace tool in the workplace. It would, in fact, seem reasonable to thaw frozen human milk using this rapid method. lhdeed, Goldblum and colleagues (Goldblum RM, et al: J Pediatr 1984; 104:380) showed that rapid, high-temperature treatment does not destroy the immunologic qualities of human milk. No change in the concentration of lactoferrin, secretory IgA, and serum IgA antibody activity was seen following rapid heat treatment for brief periods (15 seconds at 70” C). Note, however, that Quan and associates (Quan R, et al: Pediatrics 1992; 89:667) showed that microwaving at higher temperatures (72”-98” C) causes a marked decrease in the activity of all anti-infective factors of human milk. At tem-
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peratures of 20” to 25” C Escherichia co/i will grow five times faster in microwaved human milk than in slowly thawed, frozen human milk. Why microwaving causes this problem is hard to understand, The adverse effects on anti-infective factors cannot be on the basis of hyperthermia alone, since the temperatures used are not excessive. It is possible that microwaving may produce some nonthermal effects on human milk. To make a long story shorter, tell the head of the neonatal ICU to take the microwave oven home where it belongs. 16.
Q. The same director of nursing in the previous question rings you up again. The query is whether a recent switch to cloth diapers should result in any different routine management of infants in the neonatal /CU. How would you respond? A. You would have to look up an article in a recent issue of the Journal of Perinatology (Hermansen MC, et al: J Perinatol 1992; 12:72). If you switch from disposable diapers to cloth ones, you may run into a problem with inaccurate determinations of urine output, if you are using the diaper-weighing method for the purpose of quantifying urine output. Evaporation from reusable cloth diapers exposed to radiant heat is 51% at 1 hour and 82% after 2 hours, compared to almost nothing from super-absorbent diapers. Thus, you may be misled into thinking that with cloth diapers, the urinary output is diminished. A prior “Clinical Facts and Curios” described a phenomenon of superabsorbent diaper pseudoanuria (when a super-absorbent diaper feels dry to the touch even though an infant has recently urinated). Well, now we see that there is a cloth diaper pseudoanuria, since cloth diapers allow the urine to evaporate, misleading us into thinking that infants have urinated less than what they really have.
17.
Q. The next two questions have to do with the upper and lower parts of this world. The first is, what is lime disease in the Antarctic?
A. Recently described
was the case of a member of the personnel of the US. Antarctic Research Base at Amundsen-Scott Station, South Pole. This was a fellow who complained of severe pain in his right elbow. A diagnosis of acute lateral epicondylitis was made. It seems that this was traumatically induced by excessive lime squeezing. Lime squeezing is a common activity at the South Pole. Apparently, fresh limes delivered in bulk by air are stored in a “heated” refrigerator in an outside environment. A heated refrigerator is used since the average ambient temperature is -76” C and you actually have to warm the environment to 5” C to keep the limes fresh. However, because of the extremely low water content of the ambient air at the South Pole and the degree of heating required to maintain a constant temperature of 5” C, the relative humidity plummets, resulting in dessicated limes. For this reason, lime-squeezing parties are common at the South Pole in order to produce lime juice that can then be frozen for later use. Thus, the origin of lime disease in the Antarctic (Souseal MP: N Engl J Med 1992; 326:351).
18.
Q. The second frigid question is from a real-life drama. How would you deal with the following dilemma? One night in March of last year, 30 miles north of the Arctic Circle, a 5-yearold Eskimo boy was out for the evening with his father, attending the Eskimo dance performance at a local high school. The temperature was 35” F below
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zero. While walking home in the middle of virtually nowhere, the child stopped and licked a handrail and was instantly frozen to the railing by his tongue and upperlip. His father attempted to free him but could not. Instead, he resorted to a novel, effective, a/though somewhat curious means of freeing the boy. What did he do that you yourself could do as well?
A. This is not truly a fair question since presumably only about half of you could easily use the approach the father took. He urinated on the boy’s tongue, quickly freeing him (Adler Al, et al: N Engl J Med 1992; 326:351).
STATEMENT OF OWNERSHIP, MANAGEMENT AND CIRCULATION (Required by 39 U.S.C. 3685). 1. Title of Publication: CURRENT PROBLEMS IN PEDIATRICS. 1A. Publication number: 00459380. 2. Date of filing: October 1, 1992. 3. Frequrncy of issue: Monthly except for June and December. 3A. No. of issues published annually: 10. 3B. Annual subscription price: $65.00. 4. Location of known office of publication: Mosby-Year Book, Inc., 200 North La.%& Street, Chicago, Illinois 60601-1080. 5. Location of the headquarters or general business offices of the publishers: Mosby-Year Book, Inc., 11830 Westline Industrial Drive, St. Louis, Missouri 63146.3318. 6. Names and complete addresses of publisher, editor, and managing editor: Publisher-Frank N. Paparello, Mosby-Year Book, Inc., 545 Great Road, Littleton, Massachusetts 01460; EditorNorman C. Fost, MD, Dept. of Pediatrics, Room H4/452. University of Wisconsin Hospital, 600 Highland Avenue, Madison, WI 53792-4108; Managing Editor-Richard J. Wallace, Mosby-Year Book, Inc., 545 Great Road, Littleton, Massachusetts 01460. 7. Owner: Mosby-Year Book, Inc., a corporation, owner of publication, 11830 Westline Industrial Drive, St. Louis, Missouri 63146-3318. All of the stock of Mosby-Year Book, Inc. is owned by Times Mirror Company, a corporation, Times Mirror Square, Los Angeles, California 90053. 8. Known bondholders, mortgagees, and other security holders owning or holding lepercent or more of total amount of bonds, mortgages or-other securities: None. 9. Not applicable to Mosby-Year Book, Inc.
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12. In accordance with the provisions of this statue, I hereby postage rates presently authorixd by 39 USC. 3626.
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354 NO”C 2,829
599 NO”C 2,983
and complete. reques; permission
CAROI. TKUMROLD. Vice President and Journal Publicher to mail the publication named in Item 1 at the phased CAROI. TRUMROI.L). Vice President and Journal
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