Faculty Bibliography

CONTEXT/BACKGROUND:Computed tomography is routinely used for the diagnosis of appendicitis despite its high cost and its radiation exposure to patients. OBJECTIVE:To examine the usefulness and clinical relevance of computed tomography to diagnose appendicitis at a community-based academic medical center. METHODS:A retrospective review of medical records of patients who received a final diagnosis of appendicitis (according to International Classification of Diseases, Ninth Revision) from April 26, 2009, to July 27, 2009, was conducted. Emergency department and admission history, physical examination reports, ultrasonography and computed tomography reports, and operative and pathology reports were included in the review. A modified version of the pediatric appendicitis score (mPAS) was used to determine the utility of imaging vs physical and laboratory examinations. RESULTS:Charts from 36 patients, aged 8 to 22 years, were included. All patients had pathologic evidence of appendicitis. Imaging was mentioned in 20 of 36 operative reports, but no operative report mentioned imaging as a crucial factor in surgical decisions. Two of 5 patients with the elevated mPAS of 6 had undergone no imaging; operative decisions were based on history, physical examination, and laboratory results. Among the 35 patients who had mPAS values, 23 (65.7%) had an mPAS of 5 or greater. The average mPAS for all patients was 4.5. Thirty-one of 36 patients (86.1%) had typical physical examination indications for appendicitis. CONCLUSION/CONCLUSIONS:Computed tomography was used as an initial part of the diagnostic workup in most patients, rather than as a tool for only atypical cases. A tiered approach-consisting of routine clinical evaluation with mPAS, followed by imaging in only atypical cases-would likely result in diagnostic accuracy similar to that obtained with early, routine imaging. Such an approach would also decrease expense and radiation exposure to young, developing bodies.

In 1977, the American Academy of Pediatrics issued a statement calling for universal immunization of all children for whom vaccines are not contraindicated. In 1995, the policy statement "Implementation of the Immunization Policy" was published by the American Academy of Pediatrics, followed in 2003 with publication of the first version of this statement, "Increasing Immunization Coverage." Since 2003, there have continued to be improvements in immunization coverage, with progress toward meeting the goals set forth in Healthy People 2010. Data from the 2007 National Immunization Survey showed that 90% of children 19 to 35 months of age have received recommended doses of each of the following vaccines: inactivated poliovirus (IPV), measles-mumps-rubella (MMR), varicella-zoster virus (VZB), hepatitis B virus (HBV), and Haemophilus influenzae type b (Hib). For diphtheria and tetanus and acellular pertussis (DTaP) vaccine, 84.5% have received the recommended 4 doses by 35 months of age. Nevertheless, the Healthy People 2010 goal of at least 80% coverage for the full series (at least 4 doses of DTaP, 3 doses of IPV, 1 dose of MMR, 3 doses of Hib, 3 doses of HBV, and 1 dose of varicella-zoster virus vaccine) has not yet been met, and immunization coverage of adolescents continues to lag behind the goals set forth in Healthy People 2010. Despite these encouraging data, a vast number of new challenges that threaten continued success toward the goal of universal immunization coverage have emerged. These challenges include an increase in new vaccines and new vaccine combinations as well as a significant number of vaccines currently under development; a dramatic increase in the acquisition cost of vaccines, coupled with a lack of adequate payment to practitioners to buy and administer vaccines; unanticipated manufacturing and delivery problems that have caused significant shortages of various vaccine products; and the rise of a public antivaccination movement that uses the Internet as well as standard media outlets to advance a position, wholly unsupported by any scientific evidence, linking vaccines with various childhood conditions, particularly autism. Much remains to be accomplished by physician organizations; vaccine manufacturers; third-party payers; the media; and local, state, and federal governments to ensure dependable vaccine supply and payments that are sufficient to continue to provide immunizations in public and private settings and to promote effective strategies to combat unjustified misstatements by the antivaccination movement. Pediatricians should work individually and collectively at the local, state, and national levels to ensure that all children without a valid contraindication receive all childhood immunizations on time. Pediatricians and pediatric organizations, in conjunction with government agencies such as the Centers for Disease Control and Prevention, must communicate effectively with parents to maximize their understanding of the overall safety and efficacy of vaccines. Most parents and children have not experienced many of the vaccine-preventable diseases, and the general public is not well informed about the risks and sequelae of these conditions. A number of recommendations are included for pediatricians, individually and collectively, to support further progress toward the goal of universal immunization coverage of all children for whom vaccines are not contraindicated.

OBJECTIVE:The authors gathered survey data regarding the use of cellular telephones among families who reside in the New York metropolitan area and whose children receive medical care in a hospital-affiliated general pediatrics clinic. METHODS:Two investigators distributed a 34-question, self-administered survey in pencil-and-paper format to pediatric patients and the adults who accompanied them in the waiting room of a hospital-affiliated, outpatient pediatric practice in Mineola, New York. RESULTS:Completed surveys were obtained from 35 families. Twenty-eight (80%) of the 35 families completing surveys reported that at least one family member owned and used a cellular telephone. Of these 28 families, 9 (32%) reported that at least one household member aged to 18 years owned and used a cellular telephone. The mean age at which children obtained their first cellular telephone was 15.3 years. The primary reason these respondents cited for providing children with cellular telephones was safety (75%). CONCLUSION/CONCLUSIONS:The authors conclude that cellular telephone use is widespread among families in the New York metropolitan area. Although the primary reason families provide for obtaining cellular telephones is safety, convenience to household members and peer pressure also play roles.