Pediatric poisoning from trimedoxime (TMB4) and atropine automatic injectors

OBJECTIVE: To describe the effects of combined trimedoxime (TMB4) and atropine poisoning from automatic injectors (AI) in children. STUDY DESIGN: Data was collected from two sources: calls to the Israel Poison Information Center (IPIC) during a 1-year period and a cohort of children who presented to pediatric emergency departments (EDs) after unintentional injection of an AI. Demographic data and data regarding the type of AI, site and time of injection, and the clinical manifestations were abstracted. RESULTS: Data were available for 142 patients. The median age was 8.5 years (range 1.25-18 years). The dose of atropine and TMB4 was higher than the recommended dose for age in 22 (15.5%) cases. There were few side effects attributable to atropine: dilated pupils (26.7%), dryness of mucous membranes (24.6%), and tachycardia (22.5%). Compared with children injected with an age-appropriate dose, children injected with an AI that contained a dose that exceeds the recommended one were more likely to be symptomatic ( P = .029). There were no side effects characteristic to oximes, and no specific medical intervention was required. CONCLUSIONS: Unintentional pediatric atropine and TMB4 injection, even an adult dose in a small child, does not cause significant side effects.     

Inhibition of P53-related apoptosis had no effect on PrP(Sc) accumulation and prion disease incubation time

Results from several laboratories indicate that apoptosis via the P53 pathway is involved in prion disease pathogenesis. Prion diseases, among them scrapie and BSE, are a group of fatal neurodegenerative disorders associated with the conversion of PrP(C) to PrP(Sc), its conformational abnormal isoform. In this work, we tested whether an established anti-apoptotic reagent, PFT, which has been shown in different systems to inhibit P53 activity, can delay the outbreak of prion disease in infected animals. Our findings indicate that although PFT efficiently reduced caspase 3 expression in brains from scrapie sick hamsters, as well as inhibited PrP(Sc) accumulation in cell culture, it had no effect on disease incubation time or PrP(Sc) accumulation in vivo. We conclude that the P53 dependent apoptosis may not be an obligatory mechanism for prion disease-induced cell death.     

Distinguishing separable domains of cognition in human and animal studies: what separations are optimal for targeting interventions? A summary of recommendations from breakout group 2 at the measurement and treatment research to improve cognition in schizophrenia new approaches conference

At the Measurement and Treatment Research to Improve Cognition in Schizophrenia (MATRICS) New Approaches Conference, a discussion group focused on directions for future research that are critical to enhancing our understanding of the distinctions among key cognitive domains that have relevance for the development of cognition-enhancing interventions. One set of recommendations emphasizes the need for examining and optimizing the psychometric properties of relevant measurement paradigms from cognitive psychology and cognitive neuroscience. This step is critical to translating many notable advances in these basic fields into measures that would be appropriate for clinical trials. A second set of recommendations focuses on key directions for the development and application of animal models of cognitive processes that would greatly aid the discovery and preclinical testing of potential cognition-enhancing agents. As part of this process, the group noted several existing animal paradigms that have particular promise as measures in the key cognitive domains in schizophrenia identified by the MATRICS Neurocognition Committee.     

Video and CD-ROM as a training tool for performing neurologic examinations of 1-year-old children in a multicenter epidemiologic study

In lieu of traditional training of examiners to identify cerebral palsy on a neurologic examination at age 1 year, we proposed an alternative approach using a multimedia training video and CD-ROM we developed after a two-step validation process. We hypothesized that use of CD-ROM interactive training will lead to reliable and valid performance of the neurologic examination by both pediatric neurologists and nonpediatric neurologists. All examiners were asked to take one of six interobserver variability tests found on the CD-ROM on two occasions. In the first interobserver variability evaluation, 89% (531 of 594) of the responses agreed with the gold standard responses. Following annotated feedback to the examiners about the two items that had a 60% correct rate, the correct response rate rose to 93% (114 of 123). In the second interobserver variability evaluation, 88% (493 of 560) of the responses agreed with the gold standard responses. Following annotated feedback to the examiners about the four items that had a 70% correct rate, the correct response rate rose to 96% (104 of 108). Interactive CD-ROM examination training is an efficient and cost-effective means of training both neurologists and non-neurologists to perform structured neurologic examinations in 1-year-old children. It provides an effective means to evaluate interobserver variability, offers a route for feedback, and creates an opportunity to reevaluate variability, both immediately and at periodic intervals.     

Comparison of health care services for career soldiers throughout the world

Health care systems operate differently in every country and are products of historical and political factors. We compared health care systems for career soldiers in various countries with those of the Israel Defense Forces. Questionnaires requesting data regarding military health care services provided in their countries were sent to military attaches serving in Israel. The countries for which data were gathered include Argentina, Brazil, Chile, China, England, France, Finland, Germany, Hungary, Israel, Poland, Romania, Spain, and the United States. In most countries, career soldiers receive better health care services than civilians, especially in countries with military rule or under military threat.     

Sleep patterns in children and adolescents with functional recurrent abdominal pain: objective versus subjective assessment

Aim: To document objective sleep patterns of children and adolescents with functional recurrent abdominal pain (RAP), and to compare them with subjective sleep assessments and sleep patterns of healthy controls. Methods: Subjective sleep reports and sleep habit assessments were obtained from 25 adolescents with functional RAP and from 15 age- and gender-matched healthy volunteers, and were compared with continuous movement monitoring using the Actigraph for 7 consecutive days. Results: Abdominal pain before falling asleep was a unanimous complaint in the RAP group, with 29% reporting awakening from sleep by the pain. Only 25% of RAP patients assessed their sleep quality as good, compared with 87% of the control group. Objective sleep patterns measurements of the RAP patients were similar to those of the control group as well as to measurements observed in a large population of school-aged children and adolescents.

Conclusion: This study of a small group of children and adolescents with functional RAP provides objective evidence that their sleep patterns do not differ from those of normal peers, despite their subjective complaints.     

A new power Doppler ultrasound guiding technique for improved testicular sperm extraction

OBJECTIVE: To develop a noninvasive procedure that employs image processing of power Doppler ultrasound (PDUS) images of several orthogonal cross-sections of the testis to construct a three-dimensional (3D) mapping of preferential testicular regions in which spermatozoa are most likely to be found in nonobstructive azoospermic testes. DESIGN: Clinical study. SETTING: Ultrasound and andrology units in a large university-affiliated municipal hospital. PATIENT(S): Twenty-four nonobstructive azoospermic men. INTERVENTION(S): Before testicular sperm extraction was performed, PDUS images were acquired at seven cross-sections to reconstruct a 3D testicular vascularity index (TVI) matrix for spatial mapping of testicular regions in which spermatozoa are most likely to be found. The predictions based on TVI values of 107 regions were compared with the biopsy results. MAIN OUTCOME MEASURE(S): Prediction of presence or absence of spermatozoa by TVI values. RESULT(S): The prediction rate of the TVI matrix for the presence or absence of spermatozoa was 74.8%. The positive predicted value was 72%, negative predicted value was 75.6%, and specificity was 89.8%, but sensitivity was 47.3%. CONCLUSION(S): Our technique may obviate the need for arbitrary multiple biopsies that inflict some degree of damage upon testicular tissue and may increase the success rate of identifying viable spermatozoa in testicular tissue.     

Sertoli cell inactivation by cytotoxic damage to the human testis after cancer chemotherapy

OBJECTIVE: To assess Sertoli cell involvement in postchemotherapy azoospermia. DESIGN: Case report. SETTING: Teaching hospital. PATIENT(S): A 31-year-old azoospermic man who underwent cancer cytotoxic chemotherapy for non-Hodgkin's lymphoma at 13 years of age. INTERVENTION(S): Testicular biopsy specimens were obtained for sperm recovery in preparation for intracytoplasmic sperm injection. The biopsy specimens were evaluated by quantitative immunohistochemistry for the immature Sertoli cell markers cytokeratin 18 (CK-18) and D2-40. MAIN OUTCOME MEASURE(S): Extent of immature Sertoli cells. RESULT(S): A fraction of Sertoli cells (13%) in the atrophic tubules of this patient reexpressed the intermediate filament protein CK-18, which is normally absent after puberty, but not the D2-40 antigen, an Mr 40,000 a-linked membrane glycoprotein, whose loss of expression at puberty marks an irreversible step in Sertoli cell maturation. Tubules with normal spermatogenic progression lined by Sertoli cells negative for CK-18 were also observed. CONCLUSION(S): A fraction of Sertoli cells of this patient initially progressed to full maturation at puberty and reverted to a dedifferentiated state marked by reexpression of CK-18 as a consequence of chemotherapy. This inactivation of Sertoli cells caused by the cytotoxicity of the chemotherapeutic drugs may have contributed to the spermatogenic impairment and resulting infertility.     

Intraosseous vascular access in the treatment of chemical warfare casualties assessed by advanced simulation: proposed alteration of treatment protocol

Current treatment protocols for chemical warfare casualties assume no IV access during the early treatment stages. Time constraints in mass casualty scenarios, impaired manual dexterity of medical personnel wearing protective gear, and victims' complex clinical presentations render standard IV access techniques impractical. A newly developed spring-driven, trigger-operated intraosseous infusion device may offer an effective solution. Sophisticated simulators were developed and used to mimic scenarios of chemical warfare casualties for assessing the feasibility of intraosseous infusion delivery. We evaluated the clinical performance of medical teams in full protective gear. The success rate in intraosseous insertion, time to completion of treatment goals, and outcome were measured in a simulated setting. Medical teams from major hospitals in Israel, designated for emergency response in a real chemical warfare mass casualty scenario, were trained in a simulated setting. All 94 participating physicians were supplied with conventional treatment modalities: only the 64 study group physicians received intraosseous devices. The simulated survival rate was 73.4% for the study group and 3.3% for the controls (P < 0.001). Treatment goals were achieved within 3.5 min (range, 1-9 min) in the study group and within >10 min for controls (P < 0.001), and the complication rate for intraosseous use was 13.8%. Personnel satisfaction with the intraosseous device was unanimous and high. New-generation intraosseous infusions have great potential value in the early treatment stages of chemical warfare casualties. IMPLICATIONS: In a chemical warfare mass casualty scenario, the protective gear worn by medical personnel, the time constraints, and the casualties' medical condition impose limitations on the establishment of IV access during early treatment of the victims. A spring-driven, trigger-operated intraosseous infusion delivery system may offer an effective solution.