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I was pleased to read "Caring for gay and lesbian teens" (November).These teens are there in our practices but suffering alone. Occasionally,an adult former patient will say, "You never knew why I had all thosestomachaches and wanted all those gym excuses." Now, we have pink trianglesin the office.
Parents, Families, and Friends of Lesbians and Gays (PFLAG) has beenasked to speak to the middle school teachers in a nearby public school district.I will take the article with me.
Helen H. Rawson, MD
Thank you for publishing the article about caring for gay teens. My 29-year-oldson is gay. Had the medical profession been there for him as an adolescent,his life would have been much easier. Thank you for caring.
It is so important for gay youth to be open and honest with their doctorsand caregivers. Most medical professionals are not gay and aren't exposedto the tremendous obstacles gays must face in dealing with the reality oftheir lives. The adjustment is brutal, and some of these youth don't survive.Learning the cultural ins and outs and how to stay healthy are great concerns.These issues usually are addressed first in a doctor's office. Thank youfor the article.
San Francisco, CA
I have a question about a statement in "A 2-year-old with fever:Strike up the band," the October Puzzler. The authors say that thepresence of large numbers of band forms suggests that something may be causingthe younger WBCs to "demarginate" from their holding positionalong the vascular wall and move into the circulation. I understood thatthe peripheral marginal pool contains only mature WBCs, not bands. Thereforeneutrophilia caused by an increase in the marginating cells would perhapsdouble the WBCs but not increase the number of bands.
Thomas E. Hughes, Jr., MD
The author replies: I believe that Dr. Hughes has picked up an errorabout the source of band forms in Shigella infection. Although I could findnothing written in Nathan and Oski's Hematology of Infancy and Childhoodabout the makeup of neutrophils lining vessels, it would make intuitivesense that there would not be a greater percentage of band forms than moremature neutrophils in the marginal pool. I asked Dr. James A. Stockman,a pediatric hematologist (and my boss) about the marginal pool. He saysthat though Dr. Frank Oski taught that the marginal pool comprised matureneutrophils, he has never found this recorded anywhere in the literature.The stimulus to produce the bandemia actually comes from the effect of Shigellatoxin on the bone marrow. Dr. Hughes's comment is well taken.
Walter W. Tunnessen, Jr., MD
Chapel Hill, NC
"Evaluating children with delayed speech and language" (October)is an excellent presentation of a subject that is generally a weak spotin pediatricians' knowledge base. All the article lacked was a statementabout the importance of applying the same evaluation standards to boys andgirls. All too often I see little boys who are not referred for evaluationand therapy because "boys are slower than girls."
Gerald Fendrick, MD
Many pediatricians, teachers, and parents fail to recognize the effectof speech and language disorders on behavior and attention. Many childrenare labeled as having attention deficit hyperactivity disorder (ADHD) whenthe primary cause of the inattention and behavioral signs and symptoms isan undetected language disorder. Communication difficulties make these childrenfeel stressed and frustrated, resulting in inattention and impulsiveness.Teachers and parents continue to place pressure on such children to payattention and behave appropriately. The children's impaired language skillscombined with difficulties following directions issued by parents and teachersresult in a vicious cycle of even more behavior problems and inattention.It therefore is important that all pediatricians and even teachers considerthe possibility of an underlying speech and language disorder in childrenwho have this profile--before they are labeled as hyperactive and as havingADHD.
Harvey J. Kagan, MD
Virginia Beach, VA
The authors reply: Kudos to Dr. Fendrick and Dr. Kaganfor their awareness of these very real issues.
Many professionals tend to overplay gender differences during the earlyyears of language development when, in reality, the variability betweenthe sexes is slight (Fenson L et al: Monographs Soc Research Child Dev 1994;242:59,and Hyde JS: Am Psychologist 1981; 36:892).
The comorbidity of ADHD and dyslexia, in terms of reading disability,has long been acknowledged. They may be two different disorders that areoften, but not always, associated in the same child (Shaywitz BA et al:J Child Neurology 10, Suppl 1 1995; s50). What people have failed to recognize,however, is that in many cases reading problems are closely linked to languageand are also associated with attentional problems. Indeed, some preschoolchildren who do not display overt speech problems may have difficulty understandingall of the verbal language "being thrown at them." These childrenhave trouble following directions, organizing their space, and paying attention.Such behavior is misinterpreted as inattention and hyperactivity insteadof an inability to understand much of what is being said and what is expectedof them. When the time comes to learn to read, these children's languageproblems become more obvious.
Judy F. Flax, PhD
Isabelle Rapin, MD
We read your December Updates item about palivizumab. It failed to mentionthat the medication is approved for use in premature infants up to 35 weeks'gestational age and that AAP guidelines support its use for this group withappropriate qualifications.
Robert Fuentes, PharmD
Director, Medical Information
"A basic guide to cyanotic congenital heart disease" (October)was enjoyable and informative. I would like to offer comments in two areas:
(1) Although routine screening pulse oximetry to facilitate early identificationof neonates with cyanotic heart disease is not yet a "standard of care,"published preliminary observations from several centers support its use.In our community hospital, approximately 2,500 infants have been screenedin the transitional nursery as part of a pilot program. We have identifiedat least three babies in whom a congenital cyanotic lesion was not clinicallyevident at the time of the study, leading to prompt stabilization and transferto our regional tertiary center. The screening makes less likely a failureto identify a duct-dependent cardiac lesion, a worrisome possibility, beforehospital discharge. The minimal cost of this noninvasive technology addsto its attractiveness. Screening pulse oximetry deserves further study,especially for areas where early hospital discharge is common and unavoidable.
(2) In explaining cyanosis, the authors mention that "deoxyhemoglobinabsorbs light at a frequency that our eyes see as blue." The colorthat we attribute to a substance depends, of course, on light waves thatare reflected or transmitted--that is, not absorbed. Thus, deoxyhemoglobinabsorbs wave lengths other than blue. This faux pax, while trivial to theclinician, would make a physicist see red!
Michael B. Grosso, MD
The authors reply: Screening of newborns with pulse oximetry gets ourwholehearted approval, This is a simple, safe, and inexpensive method ofscreening newborns for congenital heart disease. Remember that the patient'spulse pressure should be >20 mm Hg and systolic blood pressure >30mm Hg for the pulse oximeter to work effectively. Fix the pulse oximetrysensor with dark tape and cover it with a sock or glove to prevent falsenormal pulse oximetry values. We recommend placing the pulse oximeter sensorat a foot or toe to detect right-to-left shunting across the patent ductalartery. Normal values with the Nellcor pulse oximeter during regular breathingare 95% to 100% in preterm infants and 97% to 100% in full-term infantsand children (Poets CF et al: Pediatrics 1994;93:737). Always confirm anabnormal pulse oximetry value with an arterial blood gas.
Dr. Grosso is right about why cyanosis manifests as a blue color, andwe stand corrected. Because deoxyhemoglobin reflects blue light, our eyessee blue.
Bradley W. Robinson, MD
I read "Is there a pediatric call center in your future?" (August)with interest. Such services have been in operation in other countries,such as Australia, Canada, and Israel, for quite some time. Patients inthese countries are charged a fee for using these after-hours services.Only in America, it seems, is it "understood" that physiciansshould foot part, if not all, of the bill. This is not surprising. We offerour patients our instantaneous availability by telephone, 24 hours a day,seven days a week, 365 days a year. This service is free of charge in anera of ambulances staffed by emergency medicine technicians and hospitalemergency rooms, so our patients are not really dependent on us for emergencytreatment.
In spite of this, we pediatricians know that parents often are ungrateful,demanding, and litigious. We take special pride in our relatively low reimbursement,in the superhuman demands made on us, and in our disrupted personal lives.Obviously, to "steal" a few moments of peace, a pediatrician wouldgladly pay a high premium. Is it any wonder that with our self-destructiveideals we suffer such a high burnout rate?
Steven Maron, MD