PIR Quiz-CME Credit

The American Academy ofPediatrics is accredited by the Ac-creditation Council for ContinuingMedical Education to sponsor con-tinuing medical education for phy-sicians. As an organizationaccredited for continuing medicaleducation, completion of the PIRQuiz meets the criteria for 2 hoursof credit, per issue, of the Ameri-can Academy of Pediatrics’ PREPEducation Award.

The American Academy Ot Pedi-

atrics designates this continuingmedical education activity for 2credit hours, per issue, in Category1 of the Physician’s RecognitionAward of the American Medical As-sociation.

This program has been reviewedand is acceptable for 2 Prescribed

hours per issue by the AmericanAcademy of Family Physicians.(Terms of approval: Beginningdate January 1992. Enduring Mate-rials are approved for 1 year, withoption to request renewal. For spe-cific information, please consultthe AAFP Office of ContinuingMedical Education.)

The questions for the PIR quizare located at the end of each arti-dc in this issue. Each question hasa SINGLE BEST ANSWER. Toobtain credit, record your answerson the PIR Quiz Card found in theJanuary issue, and return the cardto the Academy. (PREP group par-ticipants will receive the PIR QuizCard and Self-Assessment CreditReply Sheet under separate cover.)To receive CME credit on the 1992

annual credit summary, you mustbe enrolled in PREP or subscribeto Pediatrics in Review and returnthe PIR Quiz Card by February 28,1993. PIR Quiz Cards receivedafter this deadline will be recordedin the year it is received; with

cards from the 1992 PIR journals,accepted through December 31,1994.

The PIR Quiz card is bound intothe January issue. Complete thequizzes in each issue and send itto: American Academy of Pediat-rics, PREP Office, P0 Box 927,Elk Grove Village, IL 60009-0927.

The correct answers to the ques-tions in this issue appear on the in-side front cover.

Pediatrics in Review VoL 13 No. 9 September 1992 359

100 live births, it remains enough of

a concern that all pediatricians whoevaluate newborns should be evervigilant of the differential diagnosisand approach to children who appearto have poor perfusion during thefirst few hours to days of life. This isone of those instances where tech-nology has made phenomenal

advances with respect to the abilityto manage even severely affectednewborns, in such a way that allowsthem safe passage through a stormyinitial period of cardiogenic

insufficiency to get to a point wheresurgical intervention is not only

appropriate, but even available.It is, therefore, most important thatpediatricians be alert to the signs andsymptoms noted above and be awareof the minimal intervention necessaryto sustain life in these infants.Obviously, prompt consultation withneonatologists, cardiologists, andother interventionists is critical, butthe pediatrician can play an importantrole as the team manager withrespect not only to monitoring the

outcome of the interventions chosen,but in carefully continuing to keepthe family involved in understandingthe complexities of the technologiesthat are applied to these ill children.Even in the “high-tech” world, ourrole as general pediatricians is crucialin making the system workeffectively to enhance the outcomefor children.

Steven P. Shelov, MD

Abstracts Editor

DEPARTMENT OF CORRECTiONS

Erratum

In the June 1992 issue, there wasan error in the answer key toQuestion 6-the most appropriateregimen for the inpatient treatment of

a pregnant adolescent. The answer isB-Cefoxitin given intravenously anderythromycin (substituting fordoxycyline) given orally.

of Pediatrics

Continuing EducationPrograms

To those enrolled in PREP (Pediatrics Review and Education Pro-gram), these programs feature subject matter coordinated with thePREP curriculum. Credits earned in these courses may be appliedtoward the PREP Education Award available to Fellows and Can-didate Fellows of the Academy.

For further information contact:CME RegistrationAmerican Academy of PediatricsP0 Box 927

Elk Grove Village, IL 60009-0927800/433-9016Outside the US and Canada: 708/228-5005

American Academy

Annual Meetings

San Francisco, CaliforniaOctober 10-15, 1992

Spring Sessions

Chicago, Illinois

March 20-25, 1993

Continuing Medical

Education Courses

Advances in PediatricsNewport, Rhode Island

October 2-4, 1992

Pediatric Update IIWilliamsburg, Virginia

December 11-13, 1992

Current Conceptsin Pediatrics

Vail, ColoradoJanuary 7-10, 1993

Pediatrics 1993Maui, Hawaii

March 5-7, 1993

Washington, DCOctober 30-November 4, 1993

Denver, Colorado

April 23-27, 1994

State-of-the-Art Pediatrics

New York, New YorkMay 14-16, 1993

Pediatric AdvancesHilton Head Island, South CarolinaMay 28-30, 1993

Clinical PediatricsWashington, DCJune 18-20, 1993

PediatricTrends

Traverse City, MichiganSeptember 3-5, 1993

The American Board of Pediatrics#{174}

PROP Program for Renewal

of Certification in Pediatrics

Guides for Record Review

Otitis Media

Supplement to Pediatrics in Review

The American Board of Pediatrics

111 Silver Cedar Court

Chapel Hill, North Carolina 27514-1651

©1992 by the American Board of Pediatrics

All Rights Reserved

This guide has been prepared by the American Board of Pediatrics (ABP)

as an integral part ofthe record review required forrenewalofcertification in general

comprehensive pediatrics. Its purpose is to provide the pediatrician with criteria for

assessing patient records dealing with specific problems. Important elements to be

included in the record appear in bold-face type in the margins; other elements to be

considered are printed in italics.

The guides focus on the elements of the history and physical examination

relevant to specific problemsand are notmeant todiscouragea more thorough historyandphysicalexamination asappropriate for the patientand the particularcircumstances.

The guides will be updated periodically. Because of rapid changes in

knowledge about drugs and their availability, drugs and dosages included in these

guides should be verified in current sources.

A table of international units is included in each guide.

The guides are planned, written, and reviewed by an ABP committee

composed primarily of practicing pediatricians. Appropriate subject experts areconsulted during the preparation of the guides.

Please note that these guides do not purport toarticulate standards of care.

solely to address record keepin

They are designedg issues.

Distribution of this guide is made possible by the American Academy of Pediatrics

through a license agreement with the American Board of Pediatrics.

INTRODUCTION

Infection ofthe middleear is oneofthe mostcommon problems of infancy and

early childhood, and is responsible for substantial morbidity and expense.’� When the

first episode occurs during infancy, recurrences are common. Conductive hearing loss

is a frequent, though usually transient, complication. Some authorities believe that it

can result in delayed language development, particularly ifthe problem is recurrent orchronic during infancy.3 Less frequent but serious complications include chronic

middle ear disease, mastoiditis, structural changes of the tympanic membrane, and

central nervous system infections.

Because thepurposeofthisguide is toaddress the mostcommonly encountered

types of otitis media, this discussion will be confined to infants and children from 2

months to 5 years of age. Chronic complications, such as perforation, cholesteatoma,

and the like, will not be considered, nor will otitis media resulting from underlying

anatomic or systemic problems such as cleft palate, cystic fibrosis, or immune

deficiency.

PATIENT IDENTIFICATION

Because the clinical pauernsdifferatdifferentages, and thebacterial etiology Date of birth

tends tochange as thechild grows o1der,4� the age ofthe patient should be recorded andconsidered in the clinical evaluation and management. The increased incidence of immunizationsacute otitis media in infants and young children is probably related, in part, to nonnal Drug allergiesanatomic variations in position and length of the eustachian tubes that lead todysfunction.’� Malesare more frequentlyaffected than females, and American Indians

and Eskimos are more frequently affected than Caucasian or black patients.2 An up-

to-date record of all immunizations should be a part of each child’s medical record.Because allergy may be a predisposing factor forotitis media,’ and multiple antibiotics

or other drugs may be used in its management, it is important that any known allergies

to drugs be noted prominently on the chart.

HISTORY

In the young child, the symptoms of otitis media are usually nonspecific and Previous otitisinclude irritability, anorexia, sleep disturbance, fever, lethargy, or, rarely, dizziness or mediadifficulty with balance. Such symptoms should be recorded in the chart. The older

child may complain of earache, but ear pain is not necessarily caused by otitis media.

Pharyngitis, otitis externa, and dental problems may also cause otalgia. Many patients

have evidence ofa concurrent or recent respiratory infection, which may predispose tobacterial otitis media. The presence ofconjunctivitis may provide a clue to etiology;

adenovirus orllemophilus infections are more likely in these circumstances. Subtle or

frank signs of hearing loss may be noted.

1

Because of the tendency of otitis to recur, it is important to record whetherthere have been previous episodes, what treatment was given, the duration of each

� episode, and the adequacy of follow-up evaluation. Such information may be helpful� in determining whether one isdealing with arecurrence ora relapse ofan inadequately� treated infection, or the persistence ofeffusion. As noted above, the allergic child has

an additional risk for developing acute otitis media because of edema and increasedproduction of mucus in the nasopharynx, which may obstruct the eustachian tube.

Thus, a personal and family history ofallergy should be recorded. Breast feeding may

provide some protection against otitis media; it is useful, therefore, to note in infantswhich type of feeding has been given. There is some evidence that feeding infants

while they are supine may predispose to otitis, so a history of feeding position or of

propping bottles may be significant.2

PHYSICAL EXAMINATION

Tem rature Infants and children being evaluated for an acute illness should have theirpe body temperature recorded because high fever may indicate more serious disease and

Weight increases the need for fluid intake. Weight should be recorded for infants, and a recentweightbeavailable forolderchildren; accurate weightisneeded forcalculation of drug

Tympanic doses and provides a point of comparison in estimating recent or future losses and themembranes extent of any dehydration.

NeckThe diagnosis of otitis media rests almost completely upon the physical

Chest examination of the tympanic membranes. A careful description of the findings isessential so that subsequent examinations can be compared. Important notations arethe degree of inflammation, the presence or absence of landmarks, air-fluid levels,

bulging or retraction, perforation, and structural changes ofthe membranes. When thefindingsaresomewhatequivocal ordifficultto interpret, the performance of pneumatic

otoscopy with observation of motion of the eardrum is important in assessing the

presence of fluid in the middle ear, both in the acute and follow-up situations.2

It is also important that a general physical examination be recorded becauseotitis media is usually a complication of upper respiratory infection. The finding of

otitis media in a febrile childdoes notexclude thepossibility ofassociated disease such

as meningitis or pneumonia. Evidence of rhinitis would be apparent on examinationofthe nose. An effort should be made to determine whether the child breathes throughhis or her mouth, and to record that information. The presence of conjunctivitis orpharyngitis should be recorded. Important information from examination of the neck

should include a notation about enlarged lymph nodes, if present, and the presence ofnuchal rigidity. Results of examination of the chest should be recorded if the patienthas an associated cough or other lower respiratory symptoms.

2

DIAGNOSTIC PROCEDURES

As noted above, the diagnosis ofotitis media rests largely upon the physical Tympanocentesisexamination. Tympanometry is notroutinely indicated butmay behelpfulin providingobjective evidence if the diagnosis is in doubt; the results should be recorded in the Culture of fluidpatient’s chart. Pneumatic otoscopy and tympanometry are useful in the follow-up of

patients recovering from otitis. Audiometry is not necessary for diagnosis in the acutesituation but may be helpful in follow-up evaluation; the results should appear on therecord. The conductive hearing loss type of pattern is characteristic of fluid in themiddle ear.

Although tympanocentesis is not necessary for most patients with otitis

media, itmay be helpful in patients younger than 2 months ofage and in those who have

recurrence, chronicity, or failure of response to treatment?�4 If tympanocentesis isdone, a culture should be obtained and the results recorded, and the susceptibility of

the organisms identified. Nasopharyngeal cultures do not necessarily reflect the flora

ofthe middleear,6’7 and need notbedone unless thereisareasonotherthan otitis media,

such as purulent rhinitis.

TREATMENT

The usual therapy for otitis media is the administration of an antibacterial initial antibioticdrug, which can almost always be accomplished orally.8 The duration of therapy is therapygenerally seven to ten days,although some studieshave shown noadvantage of ten daysof therapy as opposed to five in the absence of perforation with drainage.9 Selection DU�ration ofof antibiotics is based on the knowledge that Streptococcus pneurnoniae is the most empycommon organism causing otitis, and that Hemophilus influenzae and Branhamella Dosagecatarrhalisare also very common, particularly in infants and youngchildren. The doseof the specific drug ordered, and the recommended duration of therapy, should be Antipyreticlanalgesicrecorded in the patient’s chart. The choice of drug for initial therapy should be made therapywith consideration for theprevalence of �3-lactamaseproducing strains ofll. influenzae . .

and B. cazarrhalis in the community.’#{176} A�rg1hIstamine

Antipyretic and analgesic drugs may be used as adjuvant therapy for reliefof Decongestantpain and fever.’ Antihistamines and sympathomimetic drugs (“decongestants”) have therapyno proven roles in the managementofacute otitis media, but may be helpful in selectedpatients when allergic rhinitis accompanies otitis media.’4”

In the patient who has recurrent otitis media but does not have persistent

effusion, consideration may be given to prophylactic antibiotic therapy, particularlyduring the wintermonths.’�’�’3 A singledailydose has been associated with areduct.ion

ofthe number ofacute episodes. A reasonable criterion for institution ofsuch therapyis the occurrence of at least three well-documented episodes of acute otitis media

within a six-month period. Thelargestexperience is with sulfisoxazole, 50 mg/kg/day,

but amoxicillin, 20 mg/kg/day, and the combination of trimethoprim withsulfamethoxazole,4 mgand2O mg/kg/day respectively, have been recommended.”�’3

Patients receiving such chart-documented prophylaxis should be re-evaluatedperiodically, and the need for continuation should be reconsidered in three to six

months. Intercurrent infections occurring during prophylaxis should be treated with

an appropriate antibacterial drug.

3

Corticosteroids havebeen used for ireatmentofchildren with persistent otitis

media,butevidence fortheeffectiveness isweak.’�’ Immunization with pneumococcalvaccine orllenwphilus vaccine has noapparenteffecton the incidence ofotitis media.

Children younger than 18 to 24 months of age respond poorly to unconjugated

polysaccharide antigens.’4

FOLLOWUP EVALUATION

Re-assessment of In some respects, follow-up examination may be more important than themobility of initial therapy of otitis media. Patients should be examined within three weeks oftympanuc completion of treatment for acute otitis, and the chart should document that somemem ranes assessment of the mobility of the tympanic membrane has been done. Pneumatic

Tympanocentesisi otoscopy isrnostpractical,buttyrnpanorneirycanbe utilized forthispurpose. Periodicmyringotomy re-examinatton is indicated until mob,hty of the tympanic membrane has been

restored, or until it becomes apparent that persistent effusion is present, at which timeTonsillectomy/ the therapydescribed above is indicated. Obviously, ifapatientwith acute otitis media

adenoidectomy has continued pain or other evidence of failure to respond to treatment, earlier

Prophylactic reassessmentis mandatory. In patients in whom there isclinical evidence of continuedantibiotic therapy hearing loss, or in whom speech and language development are delayed, a formal

assessment of hearing should be obtained.

The indications for myringotomy are similar to those for tympanocentesis.

Reliefofseverepain in thechild with abulging tympanic membrane can be dramatic.”Ifa myringotomy is done, a culture ofthe middle ear fluid should be obtained, and theresults recorded in the patient’s chart.

Myringotomy for insertion of tympanostomy tubes may be necessary forpersistent middle ear effusion, but the most appropriate timing for the procedure is

controversial and can be difficult to determine for the individual child.’2� “�‘� If thereis clinically significant hearing loss and delay in the development of speech, if the

patienthasbilateraleffusions,and ifthere is noresponse toa full course of antibacterialtherapy, myringotomy with tube placement should be considered. Because mosteffusions following acute otitis media resolve if the child experiences no recurrentinfections over a period of two or three months,2�” it is seldom necessary to interfere

surgically before three months’ duration of effusion. Effusions persisting for longerthan three to six months probably should be relieved surgically. A notation should bemade if tympanostomy tubes are inserted.

The appropriate place for adenoidectomy in therapy for persistent orrecurrentotitis media is controversial.’�Z”�’3 Thelargesiprospective study comparing

the effectiveness of adenoidectomy and tympanostomy tubes in the treatment ofchronic otitis mediawith effusion in4- to6-year-oldchildren found that adenoidectomyplus bilateral mynngotomies reduced the number of surgical re-treatments requiredmore than did tympanostomy tubes alone, and to the same extent accomplished by

adenoidectomyplustympanostomy tubes.’5 Theauthorsconcluded thatadenoidectomy

with myringotomy should be considered in patients over 4 years of age who have

severe chronic otitis media with effusion. They further recommended that

tympanostomy tubes be reserved for those patients in whom effusion recurs, andpersists after repeated medical therapy, particularly if hearing loss is present. In

younger or less seriously affected children, decisions regarding placement oftympanostomy tubes and adenoidectomy are best made by the pediatrician who isfamiliarwith thechild’s course, in consultation with an experienced otolaryngologist.

4

All such therapy should be noted in the chart. Finally, tonsillectomy is not indicated

for the treatment ofotitis media, but may be warranted for other indications at the time

adenoidectomy is done. Again, it is importantthatthepatient’schartcontain anotation

if any such procedure is performed.

PATIENT/FAMILY EDUCATION

Parentsshould bealerted to thesignsandsymptoms ofotiuismedia,and should

be particularly aware that recurrence is common if the first episode occurs duringinfancy. They should be aware that otitis occurs more commonly during the wintermonths, and that children in day care are at higher risk for predisposing upper

respiratory infections than children who do not attend such institutions. Physicians

may wish to stress thatrecurrences ofotitis media are morecommon in infants exposed

to tobacco smoke, which may provide an additional incentive to parents or other

caregivers to stop smoking.’6 Because of evidence that the feeding position may beinfluential, parents shouldbediscouraged from propping the infant’s bottle for feeding,

or feeding the infant when he or she is supine. The allergic child is also predisposed

to otitis media. Parents may need counseling regarding the importance of avoidingallergens and in cooperating with hyposensitization therapy. Instructions regardingswallowing or gum chewing during airplane flights, particularly during ascent anddescent, may help prevent aero-otitis media. When hearing loss is present, parents

should be told to look directly at the child when speaking, and to be aware thatprecautions may be needed to protect the child in potentially hazardous settings, as incrossing streets. Perhaps most important, compliance with prescribed therapy and the

necessity forconscientious follow-upevaluation mustbeemphasized. Physicians whoinsert myringotomy tubes should provide appropriate instructions and cautionsregarding their care.

5

REFERENCES

1. BluestoneCD, NozzaRJ: Otitis media, inNelson TexzbookofPedia:rics,ed 14,

edited by Behrman RE. Philadelphia, WB Saunders Co. 1992, pp 1609-1618

2. Paradise IL: Otitis media in infants and children. Pediatrics 65:917, 1980

3. Teele DW, Klein JO,RosnerBA, etal: Otitis mediawith effusion during the first

years oflife and development ofspeech and language. Pediatrics 74:282, 1984

4. Klein JO, Bluestone CD: Acute otitis media. Pediatr Infect Dis 1 :66, 1982

5. Wald ER: Changing trends in the microbiology of otitis media with effusion.Pediatr infect Dis 3:380, 1984

6. Schwartz R, Rodriguez WJ, Mann R, et al: The nasopharyngeal culture in acute

otitis media. JAMA 241:2170, 1979

7. Shurin PA, Howie VM, Pelton SI, et al: Etiology of otitis media during the firstsix weeks of life. I Pediatr 92:893, 1978

8. McCracken OH: Selection ofantimicrobial agents for treatment of acute otitismedia with effusion. Pediatr Inftct Dis 6:985, 1987

9. Hendrickse WA, Kusmicsz H, Shelton S. et al: Five vs ten days of therapy for

acute otitis media. Pediatr infect Dis 7:14, 1988

10. Giebink OS, Canafax DM, Kempthorne J: Antimicrobial treatment of acute

otitis media. I Pediatr 1 19:495, 1991

1 1. Bluestone CD: Otitis media and sinusitis: management and when to refer to the

otolaryngologist. Pediatr inftct Dis 6: 100, 1987

12. KaleidaPH, StoolSE: Otitis mediawitheffusion: an approach to the management

of persistent symptoms and signs in the pediatric patient. Pediatr Rev 5:108,

1983

13. Schwartz RH: Prevention of otitis media: a multitude of yellow brick roads.PediatrInfrctDis 1:3, 1982

14. LaForce FM: Immunizations, immunoprophylaxis, and chemoprophylaxis to

prevent selected infections. JAMA 257:2464, 1987

15. Gates GA, Avery CA, Prihoda DJ, et al: Effectiveness of adenoidectomy andtympanostomy tubes in the treatmentofotitis media with effusion. NEnglJMed

317:1444, 1987

16. Kraemer MJ, Richardson MA, Weiss NS, et al: Risk factors for persistent

middle-eareffusions: otitis media, catarrh, cigarette smokeexposure, and atopy.

JAMA 249:1022, 1983

6

7

CONVERSION TABLE TO STANDARDINTERNATIONAL (SI) UNITS

I. Hematology

Hemoglobin g/dL x 0.155

Platelets/mm3Leukocytes/mm3

Erythrocytes/mm’Hematocrit % x 0.01

Reticulocytes % x 0.01

= mmol/L

=count/pL= 10’cells/L

= count4iL = 10’ cells/L

= count/pL = 10’ cells/L= vol RBC/vol whole blood

= (1)

II. Blood Pressure mm Hg (torr) x 1.333 =mbar

III. Blood Gases 1 mm Hg = 133.322 PaBase excess mEq/L = mmol/LpH value = same

Iv. Blood Chemistries

Acetone mg/dL x 0.1722Acetaminophen �ig/mL x 6.62

Albumin g/dL x 144.9 or gIL x 14.49

Aldosterone ng/dL x 0.0277Ammonia mgN/dL x 0.7 14Bicarbonate mEqjL

Bilirubin mg/dL x 17.10Blood urea nitrogen mg/dL x 0.357

Calcium mg/dL x 0.25Carotene JU x 0.6

or jig/dL x 0.01863Ceruloplasmin mg/dL x 0.0662

Chloride mEq/LCholesterol mg/dL x 0.0259Complement component (C3) mg/dL x 0.01

Copper p.tg/dL x 0.157Cortisol I.Lg’dLx 27.59

Creatine mg/dL x 76.26Creatinine mg/dL x 88.40Digoxin ng/mL x 1.28

EnzymesAlanine aminotransferase

(ALT, SOFT) UILAldolase

Sibley-Lehninger units/mL

Amylase

Somogyi units/dLAspartate aminotransferase

(AST, SOOT) U/L

Creatine kinase (CK) U/LPhosphatase

Bodansky units/dL

King-Armstrong units/dL

PCO2mmHgxO.1333=kPa

‘�#{176}2 mmHgx0.1333=kPa

= mmol/L

= �.tmo1/L

= j.tmol/L= nmol/L= mmol/L= mmol/L

= Ltmol/L= mmol ureai1.�= mmolfL

= jig= jimol/L

= jimol/L

= mmol/L

= mmol/L= g,’L

= jimol/L

= nmol/L

= j.tmol/L

= jimol/L= nmol/L

=U/L

=U/L

=U/L

=U/L

=U/L

=U/L=U/L

Fatty acids mg/cL x 0.0354 = mmol/LFerritinng/mLxl =j.tgfL

a1-Fetoprotein ng/mL x 1 = jigLFibrinogen mg/dL x 0.01 = g/LFolic acid jig/dL x 22.65 = nmoVLGlucose mg/dL x 0.0555 = mmol/L

Glycerol mg/dL x 0.1086 = mmol/L

Haptoglobin mg/dL x 0.01176 = j.tmol/L17-Hydroxycorticosteroids mg/d x 2.759 = j.tmoVd

Insulin JU x 0.04167 = mg

orjtU/mLxl.0 =mU/L

Iodine jig/dL x 78.8 = nmol/LIronjig/dLxO.1791 =jimol/L

Iron binding capacity pi.g/dL x 0.1791 = j.unol,t

17-Ketosteroids mg/d x 3.467 = jimol/dLead jig/dL x 0.0483 = jimol/LLipoprotein mg/dL x 0.01 = g/LMagnesium mg/dL x 0A114 = mmol/L

or mEq/L x 0.5 = mmolfLPhosphorus mg/cL x 0.3229 = mmol/LPotassium mEcVL = mmol/LPrednisone mg x 2.79 = jimol

Proteing/dLxlO =g/L

Salicylate mg/dL x 0.0724 = mmol/L

Sodium mEq/L = mmol/LTheophylline jig/mL x 5.55 = j.tmol/L

Thyroid-stimulating hormone jiU/mL x 1 = mU/L

Thyroxine jtg/dL x 12.87 = nmol/L

Transferrin mg/dL x 0.01 = g/L

Triglycerides mg/dL x 0.01 = g/LTriiodothyronine ng/dL x 0.0154 = nmoWL

Urea nitrogen mg/dL x 0357 = mmol urea/LUric acid mg/dL x 59.48 p.mol/L

Vitamin A �ig/dL x 0.0349 = j.tmol/LVitamin 8)2 pg/dL x 0.738 = pmol/LVitamin C mg/cL x 56.78 = jiinol/LVitamin E j.tg/dL x 2.322 = j.unol/L

Xylose mg/cL x 0.0667 = mmol/L

Zinc jig/dL x 0.153 = p.unol/L

V. Urine or StoolCoproporphyrin jig x 1.53 = nmolEpinephrine jig/d x 5.458 = nmol/d

Vanilmandelic �id mg/d x 5.046 = p.mol/d

Homovanillic acid mg/d x 5.489 = jimol/d

VI. EnergyKcal x 4.1868 = K! (Kilojoule)

Rad x 0.01 = Gy (Gray) (joule/kg)

VII. Radionuclide Activity

Curie (Ci) x 37 = GGq (Gigabecquerel)

8