Diagnostic and surgical implications of child abuse

One hundred fifty-six children younger than 13 years of age with blunt abdominal injuries were reviewed, and those injured in accidents (89%) were compared with those injured by child abuse (11%). Abused children were younger (mean age, 2 1/2 years) and all presented late to medical attention with a history that was inconsistent with their physical findings. Only 65% of abused children had physical or roentgenographic signs of prior abuse, while 35% had no signs of prior abuse. The abdominal organs injured were different; 61% of accidentally injured children suffered injuries to a single, solid organ, and only 8% had hollow viscus injuries, while 65% of abused children had hollow viscus injuries. Physicians should suspect child abuse when children have unexplained injuries (especially young children with hollow viscus injuries) even when other signs of child abuse are absent, and they should suspect hollow viscus injury in abused children.     

Arthritis and hypertension in patients with systemic lupus erythematosus.

OBJECTIVE. The purpose of this study was to test the hypothesis that patients with systemic lupus erythematosus (SLE) who have, as part of their disease, persistent rheumatoid-like arthritis are less likely to be hypertensive than are other patients with SLE. METHODS. A retrospective chart analysis of 662 patients with SLE seen in a university clinic was performed. RESULTS. Data analysis revealed that hypertension and persistent arthritis were inversely correlated, particularly in those patients without nephritis and particularly in black patients. CONCLUSION. We conclude that rheumatoid-like arthritis in patients with SLE is protective against hypertension, and speculate that this protection is conferred by a higher frequency of the DR4 allele.     

Evaluation of diagnostic criteria for borderline personality disorder

A comparison of 17 narrowly defined borderline patients with 20 nonpatient control subjects indicated that certain individual and combinations of criteria may be more highly correlated with the disorder than others. Requiring any four or certain specific combinations of two or three of the five most discriminating criteria provided the optimal balance of sensitivity, specificity, predictive power, and diagnostic efficiency considerations. Fewer than five DSM-III-R criteria adequately identified the patients.     

Bilateral malignant glaucoma.

Two cases of bilateral malignant glaucoma are presented. In one case the condition developed sequentially in the two eyes; pars plana vitrectomy was eventually needed in the operated eye, whereas the condition responded to medical treatment in the fellow eye. In the second case the two eyes were involved simultaneously nearly 1 year after surgery, and the glaucoma responded to medical treatment.     

Local anesthesia for inguinal hernia repair in adolescents

Background Many centers use local anesthesia for adult inguinal hernia surgery in the setting of day-case surgery. There are no reports on, or guidelines for, use of anesthesia for inguinal hernia surgery in adolescents. We describe our initial experience with the use of local anesthesia and intravenous sedation for inguinal hernia surgery in adolescents in the setting of a day-surgery facility. Methods The charts of 14 consecutive adolescent patients (aged 12–17) who had inguinal hernia surgery from July 2004 to March 2005 were reviewed retrospectively. Intravenous sedation was administered 1–3 min before injection of local anesthetic. Sedation consisted of midazolam 0.085 mg kg⁻¹ and either fentanyl 0.85 μg kg⁻¹ or ketamine 0.085 mg kg⁻¹, according to the preference of the anesthesiologist. Additional sedation with half the initial dose was administered if required. Local anesthesia using a combination of lignocaine and bupivacaine was administered by the surgeon with infiltration in the skin and deep tissues. Results Fourteen adolescents aged 12–17 years (mean 14.8 ± 1.37), weighing 34–100 kg (mean 61.2 ± 16.5), had 15 inguinal hernia repairs with sedation and local anesthesia. All the patients were male. All completed the surgery with sedation and local anesthesia. None required conversion to general anesthesia. There were no immediate or subsequent complications. Mean time from the end of surgery to discharge home was under 2 h (mean 106 ± 36 min). Examination of patient charts did not reveal any complaints regarding the surgery or the postoperative course at the postoperative follow up visit. Conclusions The use of local anesthesia with intravenous sedation for inguinal hernia repair in the adolescent age group seems feasible and requires further prospective study.     

Medical and surgical management male infertility.

Male infertility is the result of a variety of highly treatable conditions. The critical step in treating male infertility is to evaluate properly every male partner of an infertile couple and to generate the proper treatment strategy. There are many medical and surgical options that can help most couples overcome male factor infertility. Male infertility can most easily be broken down into problems of sperm production (testicular dysfunction) and problems of sperm transport (obstruction). When applicable, medical therapies are used as an initial strategy to improve sperm production or as a preliminary therapy to boost production transiently in anticipation of a surgical sperm retrieval attempt. A range of surgical options is available to correct varicoceles, reconstruct the obstructed system, or retrieve sperm for assisted reproduction.     

Perceived adherence to prescribed treatment in juvenile idiopathic arthritis over a one‐year period

Objective

To document perceived adherence to treatment (taking medications and performing exercises) in patients with juvenile idiopathic arthritis (JIA) over a 1‐year period and to identify related factors.

Methods

We surveyed parents of patients with JIA at the Montreal Children's Hospital and British Columbia's Children's Hospital in Vancouver. Parents were asked to respond to a series of questionnaires every 3 months over a 12‐month period. Perceived adherence was evaluated on a 100‐mm visual analog scale (VAS) in the Parent Adherence Report Questionnaire (PARQ). Parental coping, distress, child function, disease severity and duration, perceived helpfulness of treatment, problems encountered, and sociodemographic data were also assessed.

Results

The mean age of our sample of 175 children was 10.2 years; mean age at diagnosis was 6.1 years and mean disease duration was 4.1 years. Perceived adherence to medications was consistently high, with average adherence at baseline, 3, 6, 9, and 12 months being 86.1, 91.7, 90.4, 92.0, and 88.8, respectively, on the PARQ VAS. Perceived adherence to exercise was lower but remained steady, with corresponding means of 54.5, 64.1, 61.2, 63.0, and 54.3, respectively. Using generalized estimating equation analysis, factors associated with higher perceived adherence to medications included perceived helpfulness of medications and lower disease severity; those associated with higher perceived adherence to exercise were younger age of the child, child involvement in responsibility for treatment, and higher perceived helpfulness of the treatment.

Conclusion

Belief in helpfulness of treatment is associated with higher parental perceived adherence to treatment.     

Cardiovascular effects of Leu-enkephalin in the nucleus tractus solitarius of the rat

Microinjections of Leu-enkephalin into the dorsal vagal complex induced hypotension and bradycardia. Both naloxone, given at a dose conferring selectivity for μ receptors, and the S antagonist ICI 154,129 prevented the cardiovascular effects of Leu-enkephalin. Naloxone was also found to decrease the gain of the baroreflex. These results suggest that Leu-enkephalin is involved in cardiovascular regulation through activation of δ-, and possibly μ-, opioid receptors in the dorsal vagal complex.     

A new regimen of amsacrine with high-dose cytarabine is safe and effective therapy for acute leukemia

Amsacrine and high-dose cytarabine (HiDAc), when administered as single agents, are effective treatment of acute leukemia. When used in combination, a high remission rate is also possible. We treated 47 patients with acute myelogenous leukemia (AML), acute lymphoblastic leukemia (ALL), and blastic phase of chronic myelogenous leukemia (CML) with a combination of amsacrine and HiDAc. The patients received amsacrine 200 mg/m2 daily for three days and, concurrently, HiDAc 3 g/m2 over three hours once daily for five days. Of 20 evaluable patients with AML in relapse, there were 12 remissions; of seven additional patients with primary refractory AML, there were two remissions, and of 12 patients with ALL in relapse, there were eight remissions. The three patients with blastic phase CML and the three patients with biphenotypic leukemia did not respond. Nausea, vomiting, stomatitis, hepatic dysfunction, and diarrhea were common, but cutaneous, conjunctival, and significant cerebellar and cerebral side effects were absent. We conclude that this regimen is highly effective therapy for AML and ALL and is also safe, eliminating the major toxicities encountered with HiDAc.