referrals to

"etiologists"

at

can

Pediatric Oncology Branch National Cancer Institute A521 Landow Bldg Bethesda, MD 20014

Hospital, permission to report his case, Safyer, MS, provided editorial

Michael R. Wollman, MD, Children's

Pittsburgh,

gave

and Andrew W. comments.

References

cancer

facilitate the clinical and laboratory evaluation of unusual pa¬ tients. DILYS M. PARRY, PHD JOHN J. MULVIHILL, MD ROBERT W. MILLER, MD Clinical Epidemiology Branch ROBERT J. SPIEGEL, MD

centers

Etiology of childhood bone Epidemiologic observations. Recent Re-

1. Miller RW: cancer:

sults Cancer Res 54:50-62, 1976. 2. Dahlin DC, Coventry MB: Osteogenic sarcoma: A study of 600 cases. J Bone Joint Surg A 49:101-110, 1967. 3. Altner PC, Simmons DJ, Lucas HF, et al: Osteogenic sarcoma in a patient injected with Thorotrast. J Bone Joint Surg A 54:670-675, 1972. 4. Jackson R, Grainge JW: Arsenic and cancer. Can Med Assoc J 113:396-401, 1975. 5. Anderson HA, Lilis R, Daum SM, et al: Household-contact asbestos: Neoplastic risk. Ann N Y AcadSci 271:311-323, 1976. 6. Mason TJ, McKay FW, Hoover R, et al: Atlas of Cancer Mortality for US Counties: 1950-1969, Publication No. (NIH) 75-780. US Dept of Health, Education, and Welfare, 1975. 7. Whitehouse D: Diagnostic value of the caf\l=e'\au-lait spots in children. Arch Dis Child 41:316\x=req-\

319, 1966.

8. McKeen

EA, Bodurtha J, Meadows AT, et al:

Rhabdomyosarcoma complicating multiple

neu-

rofibromatosis. J Pediatr 93:992-993, 1978. 9. Li FP, Fraumeni JF Jr: Soft-tissue sarcomas, breast cancer, and other neoplasms: A familial syndrome? Ann Intern Med 71:747-752, 1969. 10. Miller RW: Deaths from childhood leukemia and solid tumors among twins and other sibs in the United States, 1960-67. J Natl Cancer Inst 46:203-209, 1971. 11. Fraumeni JF Jr: Clinical patterns of familial cancer, in Mulvihill JJ, Miller RW, Fraumeni JF Jr (eds): Genetics of Human Cancer. New York, Raven Press, 1977, pp 223-233. 12. Kraemer KH: Progressive degenerative diseases associated with defective DNA repair: Xeroderma pigmentosum and ataxia telangiectasia, in Nichols WW, Murphy DG (eds): DNA Repair Processes. Miami, Fla, Symposia Specialists, 1977, pp 37-71.

Priorities for Government-sponsored Research in Pediatric Infectious Diseases was held at a the National Institutes of Health on the medical of infections on care in impact the United States: Problems and priorities for future research." A more direct title might have been, "What kinds of research in infectious disNIH support?" eases should the because that was the thrust of the two-day meeting. It is no secret that, historically, the NIH has not supported so-called clinical research that often produces information of immediate, practical application. Should there be a balanced support of basic and clinical research by the federal government? Can the government justify spending tax dollars on clinical investigations that might lead to financial advantages for pharmaceutical companies? These are difficult

May 1978, meeting In (NIH) titled, "Symposium

questions I

was

to

answer.

asked to

speak on problems in

pediatric infectious diseases that deserve investigation. I not only realized that I was inadequate for the task, but I feared that I might present a distorted

constricted view based on and experiences. for help from I called Therefore, colleagues across the country with the question, What areas of research need emphasis and future development? The 28 respondents (see acknowl¬ edgments) represent all areas of pedi¬ atrie infectious diseases. I wrote to one person in each group of investiga¬ tors, but their responses summarized the opinions of co-workers. Thus, my survey should represent a fair summa¬ tion of the majority opinion in our field. The intensity of concern was expressed by the lengthy, detailed, objective responses from most investi¬ gators. Almost without exception, they emphasized the need for studies outside their own areas of primary my

own

or

prejudices

interest. The most commonly men¬ tioned priorities can be grouped into the following seven broad categories: diagnostic methods, vaccines, diarrheal diseases, host and organism factors, studies of antimicrobials, co¬ operative studies of uncommon infec¬ tion, and miscellaneous. PRIORITIES

Diagnostic Methods Physicians who treat acutely ill chil¬ dren need help with the pragmatic

problem

of whether the child has

bacterial, viral, rickettsial, mycoplasmal or, chlamydial infection. Rapid identification of antigen by fluores¬ cent antibody, counterimmunoelectrophoresis, and latex agglutination tech¬ niques can sometimes provide an

immediate answer. Refinements and standardization of existing methods, which touch only a miniscule fraction of acute infectious diseases, are

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needed. New methods

applicable to microorganisms should be explored. A particularly crucial area is rapid identification of viral infec¬ many

more

tions.

Vaccines

Among bacterial infections, the an effective vaccine against Haemophilus influenzae type b sys¬ temic infection probably rates as the highest priority. The type b polyribosephosphate antigen vaccine, which has undergone extensive testing in recent years, has been a disappoint¬ ment and a new approach is needed. Chicken pox is the major, common contagious disease of childhood for which no effective preventive mea¬ sure has been available. Our Japanese colleagues have taken steps in this direction. This is a complex (and controversial!) area that American investigators are beginning to tackle. The possible advantageous spillover to search for

varicella-zoster infection in compro¬ mised hosts is obvious. Vaccines for common respiratory viral illnesses are probably of equal importance. Diarrheal Diseases

On a global scale, no infection of childhood commands a mortality and morbidity toll equal to that of diar¬ rhea. In recent years we have greatly expanded our knowledge of the etiolo¬ gy of infections, such as traveler's diarrhea and winter vomiting disease of infancy, but our routine laborato¬ ries lack the capability to apply this knowledge. We have no specific thera¬ py for Salmonella gastroenteritis, so elucidation of its pathogenesis is essential if we are ever going to control this common affliction. Many cases of diarrhea still defy explana¬ tion. Intensive work is urgently needed on many facets of diarrheal disease. Host and

Organism

Mechanisms of

Factors

susceptibility

and

resistance, host responses to infection, bacterial-viral interactions, and many others are basic areas that apply to all types of infectious diseases. The

opportunities for expansion of knowl¬ edge of those factors that are the essentials of host-microorganism rela¬ tionships are almost limitless.

Studies of Antimicrobials

One of the areas of pediatrie infec¬ tious disease research that has been most productive in practical terms in recent years is the practical applica¬ tion of clinical pharmacology and controlled clinical trials to antimicro¬ bial usage in infants and children. The NIH has traditionally shunned pediat¬ rie research that promised immediate, practical, applicable information for therapeutics and by default this has fallen to investigations sponsored by the pharmaceutical industry. It is a testimonial to the integrity of both the investigators and the pharmaceu¬ tical industry that the majority of such studies have been carried out and reported with objectivity. Neverthe¬ less, virtually all of the investigators polled said that it would be preferable for a financially disinterested organi¬ zation, such as the NIH, to sponsor and support such investigations.

Cooperative Studies

of Uncommon Infection

There are many important diseases in children that are sufficiently rare that no single center can conduct controlled clinical trials. This is espe¬ cially true of uncommon diseases that are inherently complex because of varied etiology, multiple clinical signs, and several possible outcomes. An example is the Neonatal Meningitis Cooperative Study Group, which has functioned for more than five years under the direction of George McCracken, MD. The NIH would seem to be a logical choice as a central organization to coordinate such stud¬ ies. Miscellaneous

There can be little argument that the most neglected areas of research have been parasitic, fungal, and rickettsial infections. Others mentioned by respondents were slow-virus and latent-virus diseases, the relation of infections in pregnancy to birth defects, allergy and infection, and nosocomial infections. In summary, there was virtual unanimity among the leaders in pedi¬ atrie infectious disease research that the NIH should expand its interests and support to clinically oriented

research, while retaining its impor¬

tant role in basic research. Another problem is the amount of research

support for pediatrie problems. It is probably fair to say that NIH support

for research in pediatrics has been substantially less than that for prob¬ lems in adults. Our government is philosophically committed to improv¬ ing the health of children but, when the research dollars are passed out, this commitment has not always been translated into action. One of the

respondents

wrote:

concerned about the dependence of upon our adult counter¬ parts. I am confident that the group trying to mount a vaccine program against zoster in adults will be much more successful than pediatricians trying to work on the preven¬ tion or modification of varicella. Cytomegalovirus infection came to the forefront when it became a problem in adult trans¬ plant patients. The emphasis on nosocomial infections reflects the emphasis in adult infectious diseases and the interest in nosocomial infections on pediatrie wards was almost an afterthought. I

am

pediatrie research

There is more truth than paranoia in his viewpoint. Central to the future of pediatrie infectious disease research is rein¬ statement of NIH-supported institu¬ tional training grants for fellows. The severe cutback of recent years has had a crippling effect on many programs. If we cannot train bright young people for the future, the future is dim. JOHN D. NELSON, MD Department of Pediatrics The University of Texas Southwestern Medical School at Dallas 5323 Harry Hines Blvd Dallas, TX 75235 The following persons responded to the ques¬ tionnaire: Charles A. Alford, Jr, MD; Philip Brunell, MD; James D. Cherry, MD; Starkey D. Davis, MD; Floyd W. Denny, MD; Hugh C. Dillon MD; Ralph D. Feigin, MD; Anne A. Gershon, MD: Samuel P. Gotoff, MD; Moses Grossman, MD James B. Hanshaw, MD; Horace L. Hodes, MD Benjamin M. Kagan, MD; Chien Liu, MD Kenneth Mclntosh, MD; Hugh Moffet, MD: Andre J. Nahmias, MD; Erwin Neter, MD; James C. Overall, Jr, MD; Robert H. Parrott, MD; Stanley A. Plotkin, MD; Paul G. Quie, MD; Mary Ann South, MD; Alex J. Steigman, MD; Joseph W. St. Geme, Jr, MD; Lewis Wannamaker, MD; Paul Wehrle, MD; and Martha Yow, MD. The proceedings of the symposium were published as a supplement to the November 1978 issue of the Annals of Internal Medicine.

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Priorities for government-sponsored research in pediatric infectious diseases.

referrals to "etiologists" at can Pediatric Oncology Branch National Cancer Institute A521 Landow Bldg Bethesda, MD 20014 Hospital, permission to...
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